Sheltering Homeless From the Mental Health Storm

BOSTON – There are no walls or even a roof. But a new type of home being built in Jacksonville, Fla., seeks to shelter to some of the city’s most vulnerable residents from the devastating effects of persistent mental illness. Through an academic-public sector collaboration between the University of Florida department of psychiatry and a comprehensive service facility called the Sulzbacher Center, a transdisciplinary team of outreach workers take to the streets to lay the foundation for "mental health homes" for the city’s large population of unsheltered homeless men and women.

Modeled after the primary care concept of a "medical home" in which multidisciplinary teams of specialists and care administrators provide comprehensive and continuous care of an individual through active communication and coordination of health care services, the fundamental elements of the mental health homes being developed in Jacksonville include psychiatric street outreach, coordination of and increased access to comprehensive care, and the integration of medical, psychiatric care, and addiction services, Dr. Richard C. Christensen said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.

Two days per week, Dr. Christensen hits the road with an outreach nurse and case managers with expertise in the areas of housing and addiction services to attempt to bring the city’s street-dwellers into the health care fold – a monumental challenge considering city census data estimates that, on any given night, there are 2,900-3,000 homeless people in Jacksonville "and there are only 600 shelter beds available," he said. "That leaves 2,300-2,400 persons who are unsheltered and outside the realm of any kind of treatment or attachment to any kind of medical system."

The outreach team is described as transdisciplinary rather than multidisciplinary, because the members do not work independently, but rather they integrate their skills and knowledge and share in clinical decision making, according to Dr. Christensen, professor and chief of the division of public psychiatry at the University of Florida, Gainesville, and director of behavioral health services at the Sulzbacher Center.

Photo credit: Courtesy of Jeanne Ciasullo  Dr. Richard Christensen and his team hit the streets to serve the homeless through a transdisciplinary outreach program.

Just as the medical home is most beneficial to individuals with difficult-to-treat illnesses, a history of nonadherence, and limited access to consistent, comprehensive care, the mental health home is potentially of greatest value to "the most highly underserved members in our community: persons who are literally and systemically homeless," he said. The corollary, however, is that those who stand to gain the most from the integrated model of treatment are often the most difficult to engage and retain. In particular, the unsheltered homeless – those who chronically live on the streets, rather than in a temporary shelter – tend to have the high rates of severe mental illness and are the least likely to receive services, Dr. Christensen said in an interview.

A recent report by the U.S. Conference of Mayors estimated that 26%-28% of the homeless people in this country have a serious mental illness, and other estimates place that percentage over 30%, with the highest rates being seen among the unsheltered homeless, Dr. Christensen said. Additionally, "unsheltered homeless persons with mental illness have high rates of co-occurring substance use disorders, making them a particularly difficult population to engage," Dr. Christensen said.

Exacerbating the engagement challenge is the fact that these individuals have a pervasive mistrust of outreach workers and the public mental health care system. "There is a fundamental difference between the unsheltered homeless and those within a shelter system or service program who are open to receiving help," according to Dr. Christensen. "The people we are targeting are not the ones who come looking for treatment. We are going to them, and they’re often not interested." Thus, engaging the clients is often an arduous task that can take days, weeks, and even months and requires adapting communication styles and expectations and, often, a fair degree of bargaining on the part of the outreach team.

"We are fortunate because [through the Sulzbacher Center] we are able to offer emergency shelter, which is sometimes the hook that gets people in, but it can take weeks and weeks to even get that point," he said.

For this reason, the goals of the program are not lofty. While there are some remarkable success stories – Dr. Christensen tells of one client with psychosis who, after months of refusing the outreach team members’ dogged efforts, eventually accepted their offer of safe housing and has since become "an active participant in her own recovery – most gains are more modest. "The success of psychiatric street outreach cannot be evaluated with the same outcome measures as those used in clinical practice," he said. Certainly, the ideal progression is to engage the client to the point where he or she is willing to accept a shelter bed, food, water, clothing, and medical and psychiatric care, followed by the development of a diagnosis and treatment plan. However, he noted, the realistic goal is to simply get the homeless individual to agree to interact with any member of the team. "When that happens, we consider it a success," he said.

Because of this, evidence-based medicine with measurable clinical outcomes takes a back seat to relationship building, intuition, and tolerance, according to Dr. Christensen. The concept of recovery is impossible without establishing a respectful relationship with each client, he said, noting that "my goal is to get them to talk to me. That’s it. We don’t discuss medication or treatment plans." By building a trusting relationship, the outreach team can begin to help each client establish social, medical, and mental health connections through "open and welcoming doors" via ongoing street outreach, easily accessible walk-in clinics, and extreme tolerance of nonadherence and missed appointments, he said.

Once clients have established a connection to a caring, compassionate community, they can begin to take steps toward healing and recovery, including participating in their own psychiatric care, entering substance-abuse treatment, reestablishing family and social connections, and, ultimately, finding stable housing, Dr. Christensen said.

Psychiatric street outreach and the establishment of a comprehensive, coordinated mental health homes for unsheltered homeless individuals is a complex, often arduous endeavor, as is the establishment and maintenance of funding needed to keep such efforts alive. "The financial aspect can be complicated. Our funding comes from many different streams, mostly in the form of grants from various sources for specific services," Dr. Christensen said. As such, the availability of services necessarily expands and contracts along with the financial support for those services, he said.

Working with homeless populations has been Dr. Christensen’s passion since medical school – in fact, he said, he went to medical school expressly to be able to provide care to the homeless. However, "even if you’re not doing this as full-time work, psychiatrists have many opportunities to link people to services by virtue of our credentials and training," he said. Toward this end, he stressed, "When treating patients in the emergency department or in the inpatient setting, look broadly at the person and not just at the constellation of symptoms in order to really identify what else is needed beside a diagnosis and medication.

"Ask yourself what else might be needed in terms of basic life needs and housing and supports." There are many things psychiatrists can do to not only provide direct care to these individuals, he said, "but also to be advocates for these people who don’t have a voice."

Dr. Christensen had no conflicts of interest to report.

BOSTON – There are no walls or even a roof. But a new type of home being built in Jacksonville, Fla., seeks to shelter to some of the city’s most vulnerable residents from the devastating effects of persistent mental illness. Through an academic-public sector collaboration between the University of Florida department of psychiatry and a comprehensive service facility called the Sulzbacher Center, a transdisciplinary team of outreach workers take to the streets to lay the foundation for "mental health homes" for the city’s large population of unsheltered homeless men and women.

Modeled after the primary care concept of a "medical home" in which multidisciplinary teams of specialists and care administrators provide comprehensive and continuous care of an individual through active communication and coordination of health care services, the fundamental elements of the mental health homes being developed in Jacksonville include psychiatric street outreach, coordination of and increased access to comprehensive care, and the integration of medical, psychiatric care, and addiction services, Dr. Richard C. Christensen said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.

Two days per week, Dr. Christensen hits the road with an outreach nurse and case managers with expertise in the areas of housing and addiction services to attempt to bring the city’s street-dwellers into the health care fold – a monumental challenge considering city census data estimates that, on any given night, there are 2,900-3,000 homeless people in Jacksonville "and there are only 600 shelter beds available," he said. "That leaves 2,300-2,400 persons who are unsheltered and outside the realm of any kind of treatment or attachment to any kind of medical system."

The outreach team is described as transdisciplinary rather than multidisciplinary, because the members do not work independently, but rather they integrate their skills and knowledge and share in clinical decision making, according to Dr. Christensen, professor and chief of the division of public psychiatry at the University of Florida, Gainesville, and director of behavioral health services at the Sulzbacher Center.

Photo credit: Courtesy of Jeanne Ciasullo  Dr. Richard Christensen and his team hit the streets to serve the homeless through a transdisciplinary outreach program.

Just as the medical home is most beneficial to individuals with difficult-to-treat illnesses, a history of nonadherence, and limited access to consistent, comprehensive care, the mental health home is potentially of greatest value to "the most highly underserved members in our community: persons who are literally and systemically homeless," he said. The corollary, however, is that those who stand to gain the most from the integrated model of treatment are often the most difficult to engage and retain. In particular, the unsheltered homeless – those who chronically live on the streets, rather than in a temporary shelter – tend to have the high rates of severe mental illness and are the least likely to receive services, Dr. Christensen said in an interview.

A recent report by the U.S. Conference of Mayors estimated that 26%-28% of the homeless people in this country have a serious mental illness, and other estimates place that percentage over 30%, with the highest rates being seen among the unsheltered homeless, Dr. Christensen said. Additionally, "unsheltered homeless persons with mental illness have high rates of co-occurring substance use disorders, making them a particularly difficult population to engage," Dr. Christensen said.

Exacerbating the engagement challenge is the fact that these individuals have a pervasive mistrust of outreach workers and the public mental health care system. "There is a fundamental difference between the unsheltered homeless and those within a shelter system or service program who are open to receiving help," according to Dr. Christensen. "The people we are targeting are not the ones who come looking for treatment. We are going to them, and they’re often not interested." Thus, engaging the clients is often an arduous task that can take days, weeks, and even months and requires adapting communication styles and expectations and, often, a fair degree of bargaining on the part of the outreach team.

"We are fortunate because [through the Sulzbacher Center] we are able to offer emergency shelter, which is sometimes the hook that gets people in, but it can take weeks and weeks to even get that point," he said.

For this reason, the goals of the program are not lofty. While there are some remarkable success stories – Dr. Christensen tells of one client with psychosis who, after months of refusing the outreach team members’ dogged efforts, eventually accepted their offer of safe housing and has since become "an active participant in her own recovery – most gains are more modest. "The success of psychiatric street outreach cannot be evaluated with the same outcome measures as those used in clinical practice," he said. Certainly, the ideal progression is to engage the client to the point where he or she is willing to accept a shelter bed, food, water, clothing, and medical and psychiatric care, followed by the development of a diagnosis and treatment plan. However, he noted, the realistic goal is to simply get the homeless individual to agree to interact with any member of the team. "When that happens, we consider it a success," he said.

Because of this, evidence-based medicine with measurable clinical outcomes takes a back seat to relationship building, intuition, and tolerance, according to Dr. Christensen. The concept of recovery is impossible without establishing a respectful relationship with each client, he said, noting that "my goal is to get them to talk to me. That’s it. We don’t discuss medication or treatment plans." By building a trusting relationship, the outreach team can begin to help each client establish social, medical, and mental health connections through "open and welcoming doors" via ongoing street outreach, easily accessible walk-in clinics, and extreme tolerance of nonadherence and missed appointments, he said.

Once clients have established a connection to a caring, compassionate community, they can begin to take steps toward healing and recovery, including participating in their own psychiatric care, entering substance-abuse treatment, reestablishing family and social connections, and, ultimately, finding stable housing, Dr. Christensen said.

Psychiatric street outreach and the establishment of a comprehensive, coordinated mental health homes for unsheltered homeless individuals is a complex, often arduous endeavor, as is the establishment and maintenance of funding needed to keep such efforts alive. "The financial aspect can be complicated. Our funding comes from many different streams, mostly in the form of grants from various sources for specific services," Dr. Christensen said. As such, the availability of services necessarily expands and contracts along with the financial support for those services, he said.

Working with homeless populations has been Dr. Christensen’s passion since medical school – in fact, he said, he went to medical school expressly to be able to provide care to the homeless. However, "even if you’re not doing this as full-time work, psychiatrists have many opportunities to link people to services by virtue of our credentials and training," he said. Toward this end, he stressed, "When treating patients in the emergency department or in the inpatient setting, look broadly at the person and not just at the constellation of symptoms in order to really identify what else is needed beside a diagnosis and medication.

"Ask yourself what else might be needed in terms of basic life needs and housing and supports." There are many things psychiatrists can do to not only provide direct care to these individuals, he said, "but also to be advocates for these people who don’t have a voice."

Dr. Christensen had no conflicts of interest to report.

BOSTON – There are no walls or even a roof. But a new type of home being built in Jacksonville, Fla., seeks to shelter to some of the city’s most vulnerable residents from the devastating effects of persistent mental illness. Through an academic-public sector collaboration between the University of Florida department of psychiatry and a comprehensive service facility called the Sulzbacher Center, a transdisciplinary team of outreach workers take to the streets to lay the foundation for "mental health homes" for the city’s large population of unsheltered homeless men and women.

Modeled after the primary care concept of a "medical home" in which multidisciplinary teams of specialists and care administrators provide comprehensive and continuous care of an individual through active communication and coordination of health care services, the fundamental elements of the mental health homes being developed in Jacksonville include psychiatric street outreach, coordination of and increased access to comprehensive care, and the integration of medical, psychiatric care, and addiction services, Dr. Richard C. Christensen said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.

Two days per week, Dr. Christensen hits the road with an outreach nurse and case managers with expertise in the areas of housing and addiction services to attempt to bring the city’s street-dwellers into the health care fold – a monumental challenge considering city census data estimates that, on any given night, there are 2,900-3,000 homeless people in Jacksonville "and there are only 600 shelter beds available," he said. "That leaves 2,300-2,400 persons who are unsheltered and outside the realm of any kind of treatment or attachment to any kind of medical system."

The outreach team is described as transdisciplinary rather than multidisciplinary, because the members do not work independently, but rather they integrate their skills and knowledge and share in clinical decision making, according to Dr. Christensen, professor and chief of the division of public psychiatry at the University of Florida, Gainesville, and director of behavioral health services at the Sulzbacher Center.

Photo credit: Courtesy of Jeanne Ciasullo  Dr. Richard Christensen and his team hit the streets to serve the homeless through a transdisciplinary outreach program.

Just as the medical home is most beneficial to individuals with difficult-to-treat illnesses, a history of nonadherence, and limited access to consistent, comprehensive care, the mental health home is potentially of greatest value to "the most highly underserved members in our community: persons who are literally and systemically homeless," he said. The corollary, however, is that those who stand to gain the most from the integrated model of treatment are often the most difficult to engage and retain. In particular, the unsheltered homeless – those who chronically live on the streets, rather than in a temporary shelter – tend to have the high rates of severe mental illness and are the least likely to receive services, Dr. Christensen said in an interview.

A recent report by the U.S. Conference of Mayors estimated that 26%-28% of the homeless people in this country have a serious mental illness, and other estimates place that percentage over 30%, with the highest rates being seen among the unsheltered homeless, Dr. Christensen said. Additionally, "unsheltered homeless persons with mental illness have high rates of co-occurring substance use disorders, making them a particularly difficult population to engage," Dr. Christensen said.

Exacerbating the engagement challenge is the fact that these individuals have a pervasive mistrust of outreach workers and the public mental health care system. "There is a fundamental difference between the unsheltered homeless and those within a shelter system or service program who are open to receiving help," according to Dr. Christensen. "The people we are targeting are not the ones who come looking for treatment. We are going to them, and they’re often not interested." Thus, engaging the clients is often an arduous task that can take days, weeks, and even months and requires adapting communication styles and expectations and, often, a fair degree of bargaining on the part of the outreach team.

"We are fortunate because [through the Sulzbacher Center] we are able to offer emergency shelter, which is sometimes the hook that gets people in, but it can take weeks and weeks to even get that point," he said.

For this reason, the goals of the program are not lofty. While there are some remarkable success stories – Dr. Christensen tells of one client with psychosis who, after months of refusing the outreach team members’ dogged efforts, eventually accepted their offer of safe housing and has since become "an active participant in her own recovery – most gains are more modest. "The success of psychiatric street outreach cannot be evaluated with the same outcome measures as those used in clinical practice," he said. Certainly, the ideal progression is to engage the client to the point where he or she is willing to accept a shelter bed, food, water, clothing, and medical and psychiatric care, followed by the development of a diagnosis and treatment plan. However, he noted, the realistic goal is to simply get the homeless individual to agree to interact with any member of the team. "When that happens, we consider it a success," he said.

Because of this, evidence-based medicine with measurable clinical outcomes takes a back seat to relationship building, intuition, and tolerance, according to Dr. Christensen. The concept of recovery is impossible without establishing a respectful relationship with each client, he said, noting that "my goal is to get them to talk to me. That’s it. We don’t discuss medication or treatment plans." By building a trusting relationship, the outreach team can begin to help each client establish social, medical, and mental health connections through "open and welcoming doors" via ongoing street outreach, easily accessible walk-in clinics, and extreme tolerance of nonadherence and missed appointments, he said.

Once clients have established a connection to a caring, compassionate community, they can begin to take steps toward healing and recovery, including participating in their own psychiatric care, entering substance-abuse treatment, reestablishing family and social connections, and, ultimately, finding stable housing, Dr. Christensen said.

Psychiatric street outreach and the establishment of a comprehensive, coordinated mental health homes for unsheltered homeless individuals is a complex, often arduous endeavor, as is the establishment and maintenance of funding needed to keep such efforts alive. "The financial aspect can be complicated. Our funding comes from many different streams, mostly in the form of grants from various sources for specific services," Dr. Christensen said. As such, the availability of services necessarily expands and contracts along with the financial support for those services, he said.

Working with homeless populations has been Dr. Christensen’s passion since medical school – in fact, he said, he went to medical school expressly to be able to provide care to the homeless. However, "even if you’re not doing this as full-time work, psychiatrists have many opportunities to link people to services by virtue of our credentials and training," he said. Toward this end, he stressed, "When treating patients in the emergency department or in the inpatient setting, look broadly at the person and not just at the constellation of symptoms in order to really identify what else is needed beside a diagnosis and medication.

"Ask yourself what else might be needed in terms of basic life needs and housing and supports." There are many things psychiatrists can do to not only provide direct care to these individuals, he said, "but also to be advocates for these people who don’t have a voice."

Dr. Christensen had no conflicts of interest to report.