Identifying occupation-based needs and services for individuals experiencing homelessness using interviews and photovoice

1.1 Economics of homelessness

The estimated average cost of a PEH each year to society is approximately $33,833. Immediate and long-term costs of homelessness can negatively impact taxpayers as well. The average cost of a visit to an emergency department is $190.00; in the last six months, four out of ten PEH have needed this service in the United States [4]. PEH utilize emergency department services about five times per year with an estimate of approximately 33% of all visits to the emergency department of any given hospital are composed of clients experiencing chronic homelessness [5].

1.2 Inclusion of occupational therapy with PEH

There are a variety of services offered to the homeless population within Connecticut. Despite efforts of many organizations, there are occupation-related needs that remain unmet [6]. Occupational therapy practitioners provide services in the community at locations such as senior centers, correctional facilities, homeless shelters, women’s shelters, after-school programs, and community mental health centers [7]. Occupational therapy (OT) is rooted in mental health. Services in relation to mental illness have shifted from hospital-based to the community. As a result, service delivery models have shifted from a medical model to a recovery model [7].

Researchers found when OT group services were provided to PEH, clients achieved their goals in several areas including money management, community mobility, addiction, personal hygiene, social skills, and diabetes management [8]. The recovery model aligns with the profession of occupational therapy, as its focus is on a long-term process that reaches the ultimate goal of full participation in community activities [7]. Occupational therapists are client-centered and the role of OT in the community is to allow individuals to live as independently as possible while engaging in meaningful activities [7]. By intertwining the community focus of occupation-based and client-centered foundation, occupational therapy practitioners can discover what meaningful activities and values surround the homeless population [7]. One example is Project Employ, a grant-funded program that provides OT services to PEH in a homeless shelter. The goal is to improve a persons’ involvement in particular roles, which is sparked by a client’s interests and preferences. Through Project Employ, occupational therapy practitioners also provide vocational rehabilitation by linking clients to community sources, providing vocational exploration, and teaching work skills [9].

Researchers indicated the importance of addressing occupational therapy practitioners’ skills and knowledge when working with PEH [10]. In Queensland, Australia, a Homeless Health Outreach Team was developed consisting of a multidisciplinary team with a primary focus on mental health and substance abuse rehabilitation. The members included OT, medical, nursing, social work, psychology, welfare, and alcohol/drug clinicians. This team actively partnered with general practitioners, non-government organizations, local councils, and government housing agencies [10]. The introduction of OT on the team allotted others to understand the role of the OT professional. The Homeless Health Outreach Team Home Health employs multidisciplinary staff in the community to provide mental health and substance abuse services to PEH [10]. The authors emphasized an occupational therapy practitioner working with a PEH requires an understanding on the individual’s needs and occupational performance issues. The occupational therapy practitioner on the team completed assessments, mental state examinations, recovery plans, and engaged clients in case management. More specifically, occupational therapy practitioners completed functional assessments to identify meaningful roles and client abilities, re-establish client life roles, and make recommendations for ongoing support. The occupational therapy practitioner on the team worked with the homeless population in a multidisciplinary, holistic way to maximize client strengths and build skills for clients to participate in meaningful everyday activities. The inclusion of an occupational therapy practitioner brought purpose, incorporation of routine, and wellbeing to a marginalized population, which draws on the foundation and skills of the profession [10].

Federally qualified health centers (FQHCs) provide another opportunity for team based care to provide primary and preventative health services to medically ill-equipped populations. These services can help reduce hospital visits and decrease the overall cost of care for various populations, such as people who earn a low-income, migrant workers, and the homeless. A proposal by researchers [11], considers incorporating OT into FQHCs to promote comprehensive services, improve client-centered health outcomes, improve experience of care, reduce severity of disease, and reduce the overall cost of healthcare for underserved populations. In order to be involved in primary care as a profession, occupational therapy practitioners must take on an advocating role and promote participation in primary care. A primary care team typically includes a physician, physician assistant, nurse practitioners, registered nurses, licensed practical nurse, and medical assistants [11]. Increased productivity demands have resulted in decreased client contact. Including an occupational therapy practitioner on the team could supplement medical services with occupation-based interventions by using resources efficiently and achieving outcomes [11]. An occupational therapy practitioners’ expertise in activity analysis, environmental modifications, and compensatory strategies is a unique perspective that could contribute to a client’s functional independence. Occupational therapy practitioners should advocate to be a larger contributor to primary care through federally qualified health centers [11].

1.3 Future roles for occupational therapy with PEH

The American Occupational Therapy Association [AOTA] [12] has stated that occupational therapists are to be part of the process of establishing communities that are livable and support full participation in meaningful occupations for all ages and conditions. Due to circumstances of homelessness, individuals may face difficulties in several areas of occupation, such as finding accessible, affordable, and appropriate housing, work opportunities, health services, and participating in civic and recreational activities [12, 13]. With specialized knowledge of health conditions, at-risk populations, and the impact of the environment, occupational therapists have a holistic skill set that may empower a homeless individual to participate in their meaningful roles and routines [14, 15]. Previous research indicates the importance of OT services in homeless shelters, federally qualified health centers, and in primary care. Occupational therapists contribute a distinct skill set and provide a unique perspective on a medical multidisciplinary team. As a profession, occupational therapy practitioners should advocate for a role in primary care and for the functional outcomes that services can provide to the homeless population.

Despite the needs, services, and potential OT roles identified in the literature, there is a lack of literature on whether or not the services offered to the homeless population are in alignment with the occupational needs of the homeless population. This study will be able to identify which occupational needs are under-addressed for PEH. The results are intended to reveal the areas of occupation that are not currently addressed by the homeless services provided in the state of Connecticut. With this information, occupational therapy practitioners can intervene and incorporate the lacking, holistic areas of occupation that are of value in the lives of the PEH.

Researchers individually listened to the recorded interviews with eight PEH in New Haven, CT. Interviews lasted between six and thirty minutes. For each interview, researchers noted significant quotes and prominent themes to facilitate the coding of data. Researchers met together to discuss each interview in depth and categorize data into four components: “Occupations Impacted”, “Services Received”, “Services Wanted”, and “Overall Themes of Findings”, and from the Photovoice component, “Meaningful Quotes”. Unfiltered data was then discussed in detail to determine the prominent occupations impacted, main services received, major services wanted, overarching themes, and meaningful quotes. Once the data had been filtered, this data was utilized as the results of the study.

Researchers also gathered qualitative data utilizing a Photovoice component in which twelve PEH had the opportunity to photograph one object and provide a quote associated with the meaningful object. The PEH were able to dialogue and share the significance of important objects such as a Bible, a rainbow token and an acrylic nail kit. The PEH expressed gratitude in being able to share what made them each a unique individual.

2.2 Limitations

The small sample size and sample comments limits the generalization of the results. The comments from an individual may not be representative for all PEH at this or other homeless shelters. All individuals are assigned a case manager. Each PEH has individual needs yet all must adhere to the rules of the shelter. The length of stay varied for the individuals in the homeless shelter. Participants are able to stay up to ninety days, however, there are instances for some to leave prior to that time or have an extension based on individual needs.

3.1 Question #1: “What daily personal activities have been most impacted since undergoing homelessness?”

Participant responses regarding impact of personal activities were grouped by areas of occupation using the Occupational Therapy Practice Framework [14] (see Table 1 for results).

3.3 Question #3: “What other services might you find helpful to individuals experiencing housing insecurity?”

3.4 Overarching themes