Weighing the options: Service user perspectives on homeless outreach services

Abstract

On a single night in 2018, over 194,000 individuals experienced unsheltered homelessness across the United States. Homeless outreach programs are often a first point of contact for these individuals, providing essential services, including connecting them to emergency shelter. Guided by the socio-rational choice model, this qualitative study aimed to address two questions: 1) How do experiences with outreach workers affect the way individuals experiencing unsheltered homelessness determine the utility of services offered by outreach programs? 2) What specific factors related to outreach interactions are involved in street homeless individuals’ decision to utilize or reject services from homeless outreach programs? Thirty-eight semi-structured interviews were conducted with street homeless individuals who had experience with homeless outreach in New York City. Interviews were first coded using a template approach followed by the use of a theory-guided approach for further analysis. Five main themes were identified that provided an understanding of individuals’ decision to engage with outreach services: credibility, transparency, offering choices, bureaucracy, and opportunity cost. This study provides insight into unsheltered individuals’ perspectives on homeless outreach workers and programs and offers suggestions for implementing micro- and macro-level changes to better meet the needs of our homeless neighbors.

Keywords

Homelessness street outreach social services rough sleeping

Introduction

Despite federal strategies to end homelessness which have led to an overall decrease in the number of individuals experiencing homelessness throughout the United States, unsheltered or “street” homelessness remains a significant problem, particularly in large cities such as Los Angeles and New York. Between 2017 and 2018, the number of unsheltered homeless individuals grew by 2.3% (or 4,300 individuals) throughout the country, to over 194,000 (Henry et al., 2018). In New York City, recent estimates identified over 3,600 individuals sleeping on the streets or subways on a single night (NYC Department of Homeless Services [DHS], 2018), though advocates believe this number to be an undercount (Toussaint, 2019).

One way in which unsheltered individuals are connected to services is through homeless outreach programs. The passage of the McKinney-Vento Act in 1987 led to targeted funding for emergency programs for people experiencing homelessness, including outreach programs (H.R. 588, 1987), which has since been reauthorized through the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009 (National Alliance to End Homelessness, 2009). The United States Department of Housing and Urban Development (HUD) defines homeless outreach broadly, as “essential services necessary to reach out to unsheltered homeless individuals and families, connect them with emergency shelter, housing, or critical services, and provide them with urgent non-facility-based care” (HUD, 2019a, 2019b). The programs that conduct homeless outreach target people in community and public settings, such as parks, streets, and soup kitchens, rather than requiring homeless individuals to seek services in more formal settings. Staff of these programs, most often referred to as outreach workers, canvas streets and other public places and engage street homeless individuals to connect them to shelter, mental health care, substance use treatment, and other services. The role of homeless outreach programs, and, by extension, their workers, is integral to engaging individuals who may not otherwise seek services (Morse et al., 1996). For example, in Pennsylvania over 25% of people experiencing homelessness identified an outreach program as their first service contact (O’Toole et al., 2007). Throughout the country, these programs are funded through a variety of mechanisms including HUD’s Emergency Services Grants, Substance Abuse and Mental Health Services Administration’s (SAMHSA) Grants for the Benefit of Homeless Individuals, and state and local sources (City Council of New York City, 2017; HUD, 2019a, 2019b; SAMHSA, 2019). New York City budgeted $81 million for outreach and drop-in services for homeless adults in 2018 alone (City Council of New York City, 2017).

In New York City, city-contracted homeless outreach workers provide 24/7 outreach to street and subway homeless New Yorkers, offering shelter, detox, and hospital placements, as well as case management services (NYC DHS, 2019). For most unsheltered New Yorkers, contacts with an outreach program are the beginning of a long process of applying for permanent housing. When the process functions as designed, an outreach worker, dispatched from an outreach program in the city, connects the individual to a case manager who is in charge of assembling the necessary documentation and paperwork required to apply for housing and other services. Frontline staff in homeless services (e.g. outreach programs, shelters, drop-in centers), including outreach workers, are usually low-level employees with varying degrees of training and education while case managers are typically para-professionals with a college education or associate’s degree (Mullen and Leginski, 2010). Professional social workers or other counselors with graduate degrees are typically part of a program’s administrative and supervisory staff rather than frontline workers (Mullen and Leginski, 2010). As of 2018, HUD requires local continuums of care (CoCs) to have a coordinated entry system, a centralized assessment and referral process which prioritizes access to services (HUD, 2017). Within this system, the importance of outreach is increased as contacts with these programs are a necessary first step for unsheltered individuals to gain access to services offered by CoCs (HUD, 2015).

Previous research has examined homeless outreach programs in regard to outcomes, cost, and provider experiences and challenges (Fisk et al., 1999; Lam and Rosenheck, 1999; Shern et al., 2000), but there has been limited research examining experiences of potential service users engaged by outreach workers. Furthermore, this research has typically focused on outcomes of specific populations, such as veterans, chronically homeless individuals, and those diagnosed with serious mental illness (Kryda and Compton, 2009; Lam and Rosenheck, 1999; Tsai et al., 2014). Although people often experience episodic or temporary homelessness, there has been limited research on the full spectrum of experiences of these individuals (Lee et al., 2010). In one qualitative study with chronically homeless individuals, Kryda and Compton (2009) found that there is a pervasive mistrust of outreach workers and the agencies that employ them. Similarly, Jost et al. (2011) found that people experiencing homelessness report negative perceptions of homeless services. Previous research recommends that relationships between outreach workers and clients should be built on trust and mutual respect, and workers should be sincere (Blankertz et al., 1990); however, in direct contrast to these recommendations, service users have expressed negative experiences with homeless service workers, including lack of compassion, disrespect, and arbitrary decision making (Hoffman and Coffey, 2008; Kerman et al., 2019).

Homeless outreach programs have been found to offer few choices to people experiencing homelessness (Tsemberis and Elfenbein, 1999) despite literature which suggests that services provided to homeless individuals should be guided not only by their needs but also their preferences (Morse et al., 1996; Petrovich and Cronley, 2015). Promoting a client’s right to self-determination is part of social work’s core ethics (National Association of Social Workers, 2017), and research has provided evidence that this is an important factor in accepting homeless outreach services. Christian and Abrams (2004) found that the uptake of homeless outreach services was influenced both by service users’ attitudes towards these services as well as their perception that they have agency in choosing to use these services.

Conceptual framework

This study is guided by the socio-rational choice model (Sosin and Grossman, 2003), a conceptual framework which utilizes components of the health belief model and behavior model of service participation. This model posits that individuals have complex ways of determining the value of services to them, including weighing the costs and the benefits of utilizing services. The weight associated with these costs and benefits is influenced by previous experiences and perceptions of service use as well as external factors such as information from other service users and features of the services offered. Previously used to understand service participation for homeless adults with substance use disorders (Sosin and Grossman, 2003), the socio-rational choice model provides a lens with which to understand individuals’ experiences with homeless outreach programs.

Sosin and Grossman (2003) describe the socio-rational choice model of service participation as having three levels, the first two which are the focus of this study. The bottom level represents the social aspect of the model, composed of “determinants” or factors of the service user’s environment, such as the structure of existing services or history with services. The middle level contains “weighing elements,” which are relevant to the weighing of costs and benefits of participation given the values of those bottom-level variables. In this middle level, individuals form perceptions of a service’s utility and the utility of alternative services or choices given the facts of the services available as well as their own histories with service use and personal factors, such as their culture and social network. Finally, the top level of “decision-making parameters” are the final elements used by the service-user to determine participation and are not able to be measured explicitly, according to Sosin and Grossman (2003).

Rationale

In line with previous literature which recommends individuals be offered services which meet their specific needs and preferences, outreach workers are expected to offer choices to street homeless individuals. However, the available options are often constrained due to policies mandating single-point-of-access and vulnerability indexing for assessing eligibility. These policies create constraints on the availability of services offered by outreach workers and subsequently for people experiencing homelessness, often creating circumstances where only shorter-term offers can be made. As such, street homeless individuals are confronted with choices that may boil down to shelter or street.

In recognizing the dual context of a growing unsheltered homeless population and the continued use of outreach workers as gatekeepers to services and housing, this study considers two relevant questions using concepts from the socio-rational choice model. First, how do experiences with outreach workers affect the way individuals experiencing unsheltered homelessness determine the utility of services offered by outreach programs? This question asks for a description of the impact of interactions with front-line providers on individuals’ perception of a service’s utility and how they weigh the costs and benefits of engaging. Second, what specific factors related to outreach interactions are involved in street homeless individuals’ decision to utilize or reject services from homeless outreach programs? Guided by this question, we aim to describe patterns in determinants and weighing elements related to experiences with outreach workers–essentially asking, what is it about interactions with outreach workers that alter perceptions of utility and therefore, perceived costs and benefits of a service offer?

Methods

Recruitment and data collection

Data were derived from a qualitative study exploring barriers in accessing services and the survival strategies of street homeless New Yorkers. Interviews were conducted from October through December 2017 (Wusinich et al., 2019). Each interview was conducted or co-led by either the first author, a licensed social worker and PhD student with extensive experience working with people experiencing homelessness, or the second author, an interdisciplinary researcher who also had experience engaging with individuals experiencing homelessness. Using geographic and gender stratified random sampling, 43 participants from Manhattan neighborhoods were recruited from areas with the highest concentration of homeless individuals (as reported by the city). Sampling areas included two large transportation hubs and a downtown public park. Interviews took place on weekdays and weekends and included daytime and evening hours to maximize representation.

To sample participants, researchers first canvassed each area on foot in about 10 to 15 minutes while identifying potential participants. Potential participants were identified as those sitting or standing with their belongings, panhandling, or being bedded down. During the initial canvassing, researchers assigned sequential numbers to each potential participant in the specified area but did not yet approach them. Researchers used a random number generator to pick a number corresponding to a potential participant. Next, researchers approached that participant, first introducing themselves and the purpose of the study, then offering a flyer describing the study and offering to answer any questions regarding participation. After that, the potential participant was asked if they would like to participate. If the individual declined, another number was randomly selected, and the process was repeated. This method was used to reduce bias in recruitment for the study.

Inclusion criteria were that participants must be at least 18 years of age, English-speaking, and currently experiencing street homelessness (i.e. not having utilized shelters or transitional housing within the last 30 days). Participants who were sleeping, visibly intoxicated, or impaired were not approached for recruitment. Individuals who agreed to participate provided written consent.

After participants consented to the study, researchers facilitated semi-structured interviews about use of services and experiences of being homeless. The interview guide was developed by the authors, who drew from their direct experience working with individuals experiencing homelessness, and in consultation with advocates with previous experiences of homelessness; it was also pilot tested with two street homeless individuals who provided feedback which led to slight revisions of the initial guide. Interviews ranged from 15 min to 2 h and focused on service utilization, including shelters, transitional housing, and drop-in centers, and interactions with homeless outreach programs. After completion of the interview, participants were compensated with $20. All study protocols were approved by the institutional review board at New York University.

Data analysis

All interviews (N = 43) were audio recorded, transcribed verbatim, and reviewed for accuracy. Transcribed interviews were then uploaded to ATLAS.ti (Version 8.2, 2018) for analysis. The full interview dataset was initially coded as part of the larger study (Wusinich et al., 2019), in which the codebook was created using a template approach, utilizing sensitizing concepts in developing an initial set of codes (Crabtree and Miller, 1999; Padgett, 2017). During this process, participant experiences with outreach programs and workers were coded as “outreach experiences.” Upon completion of this initial coding, all excerpts coded as “outreach experiences” were selected and second-level coding was used to inductively identify patterns and themes in order explore the specified research aims related to socio-rational choice.

For this study, a theory-guided approach was used to analyze and interpret the data (Gilgun, 2015). By “theory-guided” we refer to the influence of socio-rational choice theory and prior knowledge of related research as sensitizing the analysis, rather than beginning with fully inductive open coding. Guided by this study’s two research questions, this article’s first and second author completed second-level coding of the “outreach experiences” data to identify higher level themes addressing how street homeless individuals make choices about services offered by homeless outreach programs within the context of the socio-rational choice model. These authors met and discussed emergent themes until consensus was reached in relation to the two questions. As common in theory-guided research, negative case analysis was used to identify patterns and exceptions to these patterns within individual experiences (Gilgun, 2015).

Findings

Participants

The final sample consisted of 38 street homeless individuals. Only individuals who reported a history of engaging with homeless outreach programs were included in this analysis. Twenty-nine participants (76.32%) were male and the remaining nine (23.68%) were female. Over half (n = 21, 55.26%) were white, nearly a third (n = 12, 31.58%) were Black/African American, and five (13.16%) were Latinx/Hispanic. Participants ranged in age from 21 to 74 years old.

Length of time homeless and previous experiences of homelessness varied significantly between participants. While all participants reported their length of homelessness, some described it in total years homeless (i.e. “on and off”), while others specified the length of their current homeless episode. Length of time homeless ranged from a current episode of homelessness of three weeks, to seventeen years “on and off.” Twenty participants (52.6%) reported lifetime homelessness (including current and total homelessness) of greater than one year.

Themes

These findings are in response to our research questions: how do experiences with outreach workers affect the way individuals experiencing unsheltered homelessness determine the utility of services offered by outreach programs, and what specific factors are involved in their decision to ultimately accept or reject services? Five main themes were identified: 1) credibility, 2) transparency, 3) offering choices, 4) bureaucracy, and 5) opportunity cost. Our first two themes emerged from participants explaining that transparency and credibility of outreach workers are impactful in their decision to engage with services. In “offering choices,” we present participant views on the importance of being given appropriate choices and having their choices respected. The fourth theme “bureaucracy” explores participants’ insights into the bureaucratic system in which the outreach workers, programs, and services are situated. Finally, “opportunity cost” contains participant comments on the time and energy cost of engaging with outreach workers.

Credibility: “They try to help me, and I never see them again.” Based on past experience, stories from other service users, and perceptions of outreach workers’ intentions, individuals made a judgment of how much to believe or buy into the offers made by outreach workers. SP42 expressed that he had worked with multiple outreach workers but “received no help” and that “there is always some excuse.” This participant explained that “all they’re [outreach workers] doing is monitoring our movements” and that “this is a racket. They’re making money off of it. The more homeless people there are, the bigger their budget gets … You think they really want to end homelessness? If they ended homelessness, they’d be out of a job.” This perception that the intentions of outreach workers were not actually aimed at addressing homelessness was common. Another participant (SP22) described a similar negative experience:

They [outreach workers] just come in the morning and ask me stuff…They act like they’re doing something. They see me every day. They walk up to you every day and talk to you like they’re doing something. And walk around. Full of shit people.

Further, many participants felt that outreach workers did not follow through with offers of help. In describing his conversation with an outreach worker, SP35 said, “What do they tell me? To hold on, wait, stuff like that. You know what I mean? They try to help me, and I never see them again. It’s like a one-time thing; I see one person, never see them again.”

Believing whether or not outreach workers were genuinely moving them through a process which would end in housing played a large part in willingness to engage. One participant (SP5) who was actively engaging with outreach said, “I’ve got to be patient.” This participant believed that they would be in housing soon, explaining, “before it’s cold, I’ll be there before next year. I know I will. The way he [the outreach worker] was talking, you know.” A participant (SP23) who was not actively engaging with outreach workers explained simply that he chose not to work with them because “I don’t trust them.”

2. Transparency: Superficial encounters vs. meaningful engagement. A related factor in choosing to accept services was the perceived transparency, or lack thereof, related to the aims of outreach, the process of obtaining services, and what outreach workers were actually offering.

SP33 described his experience, “They [outreach workers] just come here for about five minutes, uh, to check your name. They say they’re gonna go back to the office. So, I guess putting your information or something and that’s it. But there is no explanation or anything.” Superficial encounters were a commonly reported experience by participants, including an outreach worker asking for their name and date of birth and asking how they were doing, without offering concrete services or support. SP42 described, “They wake us up, take your name down. Basically, we’re like batteries to them; we’re energy to them.” Similarly, SP37, when asked if he had engaged with outreach workers, said “Yeah, occasionally when I’m out in certain places. They would take my name.” The lack of explanation or further information was frustrating for participants whose immediate need of finding housing was not addressed in these interactions. SP20, recalled his conversation with an outreach worker:

I said, “It’s getting very cold out. If you can’t get me in someplace, you know, then I really don’t need your help. Comin’ around asking me how I’m doing, how I’m doing. How do you think I’m doing?” … You know, either help me or leave me alone.

Others described not knowing what an outreach program’s purpose was and finding the outreach workers themselves were not always clear. SP36, a pet owner, described his experience with an outreach worker who initially offered him services only to come back and say they do not accept pets:

[The outreach worker] did seem to be a little unhelpful, because, like I was saying, the case managers didn’t even know, like, their full guidelines. They didn’t know … that they couldn’t help people with animals or anything like that. So they were, they were pretty unhelpful for me.

Another participant (SP10) explained that after a bad experience with an outreach worker from one program, he chose to work with an outreach worker from another program who was more transparent:

It’s been hectic. Like we’ve been waiting and waiting for them [an outreach provider] to place us somewhere. They’re telling us that there’s nowhere to place a couple. They don’t work with couples. I’m like, “How can you say you don’t work with couples? I’ve seen you place couples in shelters before.” It kind of got me upset. It got her [his partner] upset as well … We said we’re gonna work with somebody else … [A different outreach provider] was more useful … they really explained themselves—tell us exactly what their jobs are. Unlike [the first provider]—they just do their job and then walk off, but they don’t really explain nothing.

3. Offering choices and supporting autonomy. Some participants described their experiences with outreach workers as helpful and expressed that they offered choices of available services, which allowed for autonomy in decision making. Others discussed the importance of making decisions about service use that was best for them. SP38 spoke about his outreach worker’s willingness to support his autonomy in making decisions about housing placements:

He [outreach worker] told me, “Listen, I’m gonna make a little deal with you, okay? I mean, you don’t have to accept it if you, you know, say, don’t want to.” So, his offer was okay, “Pick whatever day you want me to come and pick you. We have two facilities. We have one up in East Harlem, another one in the Bronx … and then you can decide which of the two you want to go to … ” I said, “Okay, okay, okay, that sounds like a good idea. I’ll take you up on that.”

The “deal” the outreach worker made with SP38 to tour two available options and choose one or neither provided an opportunity for SP38 to make his own decision regarding transitional housing options. However, this was the only such experience of choice that we heard about.

SP4 told us that she described her needs to an outreach worker and they were able to assist her with what she wanted: “ … they just walked up and asked me if I needed help I said “Yeah I need help with a lawyer, a legal aid lawyer” and they asked me why, and I told them because I need to get a divorce from a man who was beating me and stuff, that’s why I came to the streets and they were like “Okay!””

While in some instances outreach workers offered services that participants wanted and appreciated, others viewed them as unable to offer these types of choices. SP44 said that outreach workers offered services that he did not need or find helpful. He explained that they might offer “a shelter … .some food, clothes, stuff like that;” however, he continued, “I can get all that stuff on my own. … I’m trying to get [an] apartment. That’s my problem.” Similarly, SP8 identified that the services offered were not particularly useful to her, saying, “I already have my record of homelessness on files so I don’t know what else they could offer me - like I’m already trying to get all the government services I can.” Another participant described his decision to not work with an outreach program after they informed him they would not offer him transitional housing with his wife. He chose to receive services elsewhere, saying, “So, that’s why we are going through the veterans [the Veteran’s Administration], because the veterans will, you know, do it-do it for us together because, you know, we're legally married. But it makes no sense to me if they wanna house us separately.”

4. Bureaucracy: Burden of bureaucratic constraints on decision making. Through their interactions with outreach workers, participants became aware of the bureaucracy of the system through which services are offered and mentioned it frequently when describing their experiences. Participants reported onerous requirements such as needing to be seen multiple times within a specified time frame to verify the chronicity of their homelessness (essential to their eligibility to receive services reserved for those deemed “chronically homeless”). Across participants, there was confusion about where and when they were supposed to be seen and by whom. SP36 explained, “Cause a lot of the housing … they have to see you a certain amount of times or run into you for a certain amount, a period of time, or whatever the case may be.” SP28 described how he was waiting to move forward with the outreach programs, saying, “I’m just waiting for them [outreach workers] to go, “Okay we’ve seen you enough times, so we’re ready to go to the next step.” SP16 had a similar experience:

… the way their program is run, is like—they [outreach workers] had to see [me] out here certain amount of times before they actually can like, I guess, put you up … [in] an apartment or whatever they do, you know. And it’s like, I think, a minimum of like six months they have to see you outside for.

There was also little coordination between outreach workers and the city-run shelter system which could be accessed directly. One participant (SP35) described his frustration working with outreach workers, who told him that he had unknowingly lost his place in a queue for a transitional housing bed, which was only accessible through an outreach program, due to previously accessing emergency shelter. He said,

They [outreach workers] kind of messed me up, because I went to [a city shelter] system first. They [outreach workers] came out here to look for me. They had a bed for me and everything. And when they came to get me, they told me that I have to sleep for a month outside in order for my name to get cleared from the system [the city shelter roster] in order for me to be in their program.

The perception of a moving target and unclear standards for program eligibility was common in experiences with outreach workers, which added to the view that these services are entrenched in bureaucracy.

Most participants knew that an outreach worker was the necessary connection to acquiring a case manager, beginning the long process of obtaining documents, such as identification, and taking other required steps to obtain housing. When outreach workers helped them navigate this bureaucracy, participants reported more positively about their outreach experiences. SP9 described his experience of beginning this process with an outreach worker as worthwhile:

They’re pretty good. They’re about, you know, looking for housing for you, helping you with other things, getting some documentation. Like, I didn’t have my social security card, or my birth certificate, and they were able to get me original copies, you know, and help me with that.

SP14 had a similar experience with outreach workers assisting in obtaining documents, saying, “I got all my IDs back through them.”

SP4, a victim of domestic violence who was ineligible for housing due to her marital status with her abuser, also expressed that outreach workers were helping her go through the steps necessary to gain housing; in her case, step one was getting a divorce. Despite bureaucratic eligibility constraints, outreach workers provided services that helped this individual navigate the initial steps in the process of obtaining housing. Although in these instances, outreach workers provided relatively high utility services within a bureaucratic framework, it is important to remember that these participants were still choosing to stay on the street (instead of in a shelter) as they worked toward safer housing options, which were not immediately available due to systems in place.

5. Opportunity cost: Is it worth the effort? The time and energy required to move through the process of obtaining services, including case management and housing, are often substantial and were specifically cited as reasons for not accepting services and engaging with outreach workers. SP6, speaking about his frustration with outreach workers, summarized that “they [outreach workers] make it a big, drawn-out process” and that “they got issues—they hit you with the bullshit where they gotta say, ‘sorry.’ They gotta see you five times in the same area. You know, that’s ridiculous.” Another participant (SP41) said, “I don’t wait for the shelter system because it’s like they [outreach programs] take their time about it because they get a certain amount of money from the state to house, you know what I’m saying? To house homeless people … They wanna help, but they also wanna help people that been out there for a minute.” This participant did not engage with outreach workers because the wait was not worth it, but he also had an understanding of the outreach programs’ rationale that the wait is necessary for deciding how to distribute services, though that was a less common opinion.

On the other hand, when the cost seemed appropriate to the services offered, participants seemed more willing to engage with outreach workers. For example, SP43, an actively engaged participant, explained his preference for a low-threshold transitional housing placement, “my friend just got in his place yesterday I think, and it only took him like three months, but it really isn’t that bad considering you get a place for free for a whole year.” SP7 was also positive about the transitional housing process and in response to a question about whether it was complicated, answered, “No … they interview you, and they let you know where you gonna be at … So they’ll come and let me know and tell me I got a bed.” He continued, “I’m definitely going there [transitional housing program] soon because of the bed … Everybody that I know that’s been there got a place, they said their place there is nice, it’s clean,” reflecting that participants’ response to a desired placement included a willingness to wait.

Discussion

We identified five main themes that described factors associated with perceptions of utility of homeless outreach services including credibility, transparency, offering choices, bureaucracy, and opportunity cost. Through the lens of the socio-rational choice model of service participation (Sosin and Grossman, 2003), our findings provide evidence that service-users make decisions to engage with outreach by calculating weighing elements, such as utility of the offered service and alternative options, which are shaped by determinants in their environment (e.g. the structure of services available and past experiences with outreach). In a similar vein as Sosin and Grossman’s (2003) conclusion, our application of the socio-rational choice model does not place all responsibility on the system, on outreach workers, or on individual service users; rather, it provides a partial understanding of how service users think and respond to certain kinds of service offers and to outreach workers. Understanding these component parts of the decision-making process reveals areas of the system that can be improved, including what services are offered and how outreach workers engage with service users.

In line with our findings, previous studies found that a lack of trust in outreach workers was a reason for declining services (Kryda and Compton, 2009) and that individuals consider the credibility of outreach workers and negative perceptions of services in their choice to engage (Jost et al., 2011); however, these studies only included chronically homeless individuals, whereas our study interviewed service users who had been homeless for varying lengths of time. Positive characteristics of outreach programs reported by participants in this study included providing choices in services and assisting individuals in obtaining concrete services. Offering services aligned with individual preferences has been found to be effective in ending episodes of homelessness (Padgett et al., 2016).

Further, our findings suggest that bureaucratic systems within which outreach programs must work can deter people experiencing homelessness from engaging and can influence their decision to engage with programs in the future. Previous research found similar perceptions of outreach, including perceiving service providers as “inefficient, nonresponsive, and ineffective,” viewing the system itself as a barrier, and feeling that available services did not meet their needs (Petrovich and Cronley, 2015: 319). Another study found that the inability of services to adapt to an individual’s needs was a common aspect of a negative service use experience (Kerman et al., 2019).

These findings contribute to a larger understanding of engagement with outreach programs among individuals experiencing unsheltered homelessness. While other research has identified that characteristics of the offered services themselves are a large part of the decision to work with outreach programs (Wusinich et al., 2019), the current research explores the experiences of engaging with outreach workers and programs as well as insight about outreach-related barriers that may be useful for providers. These findings support offering options to unsheltered individuals and respecting their autonomy in making service use decisions. Blankertz et al. (1990) notes that clear communication, such as telling clients a specific time the next outreach visit will occur or providing concrete information about available services, is essential in developing trusting relationships with unsheltered individuals. At a macro-level, social workers can engage in advocacy and develop policies that minimize bureaucracy in accessing housing. Policies, both at the program and community level, should ensure that outreach workers are able to offer services which align with HUD’s core elements of Coordinated Entry, including accurately assessing individual needs and preferences and providing low-barrier housing options (HUD, 2015).

Strengths and limitations

Unlike previous qualitative research on homeless outreach that used convenience sampling and recruited chronically homeless individuals only (Jost et al., 2011; Kryda and Compton, 2009), our study randomly sampled from multiple diverse neighborhoods and included individuals who had been unsheltered both long and short-term. Our sample was not only stratified by neighborhood but also by gender, with the aim of recruiting a sample proportional to the street homeless population in Manhattan. Multiple strategies, including co-coding and group debriefing (Padgett, 2017), were used to enhance the methodical rigor of this study.

Because interviewees in this study were all experiencing street homelessness, our findings provide insight from individuals who are the main target of outreach programs. This is a strength in that these individuals have lived experience of choosing or not choosing to engage with services and can provide insight into what outreach programs are doing well and what areas can be improved—whether that is how outreach workers try to engage or simply how the services themselves are structured—a factor beyond the relationship with outreach workers. However, our sample may be limited in that individuals who have been provided shelter or permanent housing through outreach programs were not part of this study’s sample. Our sample was likely biased because participants may have been more likely to be on the street due to negative experiences with services and outreach programs.

It should also be noted that there are multiple agencies that provide outreach to people experiencing homelessness, and individual teams of outreach workers may have varying engagement techniques and policies. That said, many of the experiences described in our results were attributed to every agency named in interviews, which may mean that these problems exist across agencies and need to be addressed universally. Further, although there are multiple homeless outreach agencies, they are all funded by and operate within the same bureaucratic system. In many ways, New York City has a unique landscape of homeless outreach services as well as policies that shape available services and housing. Therefore, some of our findings may be limited in their applicability to other U.S. cities as well as cities in Canada, the United Kingdom, and others reckoning with street homelessness. However, factors that impact relationships between service users and providers and that determine an individual’s decision to engage may be generalizable to other locations, as many of our findings were similar to previous studies.

This study provides further evidence that interactions with outreach workers are an important part of an individuals’ decision-making regarding engaging with homeless outreach services. Based on our findings and other literature, we recommend that outreach workers provide greater consistency in their engagement with service users and more transparency in service eligibility criteria, while respecting service users’ autonomy. We recommend policies that allow outreach programs to reduce bureaucratic hurdles and waiting, to simplify the process of obtaining housing, and to provide services that actually meet individuals’ needs. A large part of any strategy to address homelessness must include improving the ways in which outreach workers provide services and what they are able to offer individuals experiencing homelessness.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Lynden Bond

Deborah Padgett

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