Abstract
BACKGROUND:
Graduate occupational therapy students collaborated with an Area Health Education Center (AHEC) to address occupational therapy’s role in intervening for individuals who are homeless.
OBJECTIVE:
The purpose was to provide educational resources on specific needs related to health and wellbeing to individuals who are homeless.
METHODS:
A variety of methods were used to gather information on common needs of the homeless population related to health and wellbeing, community integration, and development of routines. Initial data was collected through the use of a needs assessment for nine participants with thirteen questions followed with a weekly visit to a homeless shelter. The weekly visits allowed the students to build rapport and trust with the residents to gain an understanding of individual perspectives and barriers to occupation.
RESULTS:
The students worked with residents how to best access community based resources and services related to occupational needs. Specific needs were identified, and further resources were provided to support community integration, independent living, and self-management.
CONCLUSIONS:
Preliminary findings provided a basic understanding of the foundational needs of individuals to be used to support future research linking occupational therapy to the homeless population to achieve individual goals, improve health and wellbeing, and enhance life skills management.
Introduction
For every 10,000 people in the country, 17 are experiencing homelessness [1]. According to the American Security Project, homelessness has a large economic impact on society due to the frequent use of publicly-funded services and institutions [2]. The United Nations Declaration of Human Rights, Article 25 states that every individual has the right to a standard of living that promotes health and well-being [3]. This includes housing, medical care, and essential human needs, yet it was found that there are several barriers in place inhibiting individuals’ ability to end homelessness. One issue is the lack of preventative healthcare services. This may lead to acute, life threatening conditions including heart attack, stroke, and organ damage because they were unable to receive care until the disease has advanced [4]. Research has shown there are higher rates of mental illness within the homeless population [5]. This creates a societal issue because emergency departments are not equipped to meet the psychosocial needs of the homeless population and lack the capacity to help them with housing, substance abuse treatment, or mental healthcare [6]. One solution is to provide widely accessed and free healthcare to reduce homelessness rates as it relates to its medical nature [7]. Another solution is to hire an occupational therapy practitioner. Occupational therapy is able to provide a holistic perspective on homelessness, by analyzing both physical, mental, or emotional limitations that may affect a person’s ability to successfully engage in their daily occupations.
Significance to occupational therapy
Through the promotion of health and wellbeing, occupational therapy practitioners (OTPs) facilitate the development of skills, promote healthy routines, and modify the environment for increased occupational function [8]. The origins of occupational therapy are rooted in mental health, thus, this profession has gained a prominent role in the mental health field [9]. Care for the homeless uses the traditional mental health skills that OTPs acquire, and combines the knowledge of community-based interventions. Throughout the history of this profession, mental health services have shifted from hospitals to the community setting and there is substantial evidence in support of occupational therapy in community mental health, including the homeless population [9]. People who are homeless may lack opportunities to engage in meaningful occupations which may negatively impact their health, well-being and quality of life [10]. Occupational therapy practitioners have the responsibility to address factors influencing health disparities, which involve the differences in adverse health conditions that exist between specific populations [11]. OTPs can successfully fulfill a role in the homeless population by providing interventions specific to each individual’s needs, challenges, strengths, and goals [8]. Through the understanding of disease management, the impact of the environmental context, and the importance of health promotion and wellbeing, OTPs can provide evidence-based services to benefit this population [12]. Interventions may include re-establishing life roles and routines, education and training in basic activities of daily living, community reintegration, and job training [12]. OTP’s can also address unique unmet needs and identify resources for the homeless population. These services directly correlate with occupational therapy goals to promote health, wellbeing, and social participation among all people [8].
Significance to society
A critical problem to society is the substantial health care costs, with one specifically being the costs of emergency room visits. Individuals who are homeless are more likely to utilize emergency department services than the general public due to lack of regular care [6]. Individuals who are homeless visit the emergency room, on average, five times per year, each visit costing approximately $3,700, amounting to $18,500 spent annually for the average visitor. Furthermore, on average, individuals who are homeless spend approximately three nights per visit in the hospital, which can add up to $9,000 [6].
Studies have shown that due to housing instability people who are homeless experience secondary issues such as chronic diseases which increases the number of emergency visits and the need for supportive medical interventions. Homelessness can lead to chronic disease just as chronic disease can lead to homelessness. Individuals who are homeless utilize emergency rooms, crisis response and public safety systems at a higher rate than the general public [5]. If there continues to be a lack of resources and education for individuals who are homeless concerning the areas of health and wellbeing, then difficulties regarding physical, mental, and emotional wellbeing may lead to an occupational imbalance. The purpose was to provide education and resources on needs relating to health and wellbeing, community integration and routine development to individuals who are homeless residing at an emergency shelter in Connecticut.
Methods
The students participated in a variety of local and community events related to poverty and homelessness to expand their perspective of the obstacles faced by this population. Initial data was collected through the use of a modified needs assessment and weekly visits that included informal meetings and socializations during dinner and with leisure pursuits with the residents over the course of eight weeks. Together these methods allowed the students to learn about the population while meeting in person to determine how the role of occupational therapy can best benefit the population at the emergency shelter.
Needs assessment survey
Initial data collection was completed through a modified version of the AHEC Collegiate Health Service Corps Needs Assessment. The purpose of the needs assessment was to understand the predominant healthcare concerns of the residents. This assessment provides questions on demographics, knowledge of health-related topics, and physical health and wellbeing. It was modified to remove inapplicable questions and include questions on mental health, length of homelessness, and current health problems. The assessment was administered to nine participants and consisted of thirteen questions with a combination of multiple choice and multiple selection answers.
Weekly visits to emergency shelter
The students, faculty advisor, and AHEC members visited emergency shelter weekly for one hour for a total of eight weeks. The residents and students engaged in conversations that addressed the various needs and barriers to success within the community. Working within the scope of occupational therapy practice, the students built rapport and trust with the residents through the use of leisure exploration and social participation experiences. The students additionally contributed to the daily routines that exist at the emergency shelter including meal time preparation. During these activities, conversations arose that guided the students to develop resources based from the primary concerns shared by the residents.
Participants
Participants of this project resided at the emergency shelter during its open months of December to April. Inclusionary criteria for participation in the project included: at least 18 years old and actively utilizing services at the emergency shelter. Individuals were excluded if they were not present at the shelter at the time of the eight student visits.
Limitations
This emergency shelter was chosen based on a request for programming needs. One limitation was recruitment of a consistent group of participants. Despite clients being allowed to stay for the duration of the winter months, participants were not consistent due to a variety of reasons. Therefore, the information gathered was compiled based on consistent participants during the eight visits.
Data collection
Following the weekly visits two surveys were administered to assess the resident’s satisfaction with the student visits. Consent was obtained with agreement to complete the survey. Throughout the development and implementation of these methods, the students collaborated with members of the Southwestern region of the National Area Health Education Centers (AHEC). Southwestern AHEC is a non-profit organization that was established as part of the Connecticut Area Health Education Center (AHEC) program through Health Resources and Services Administration (HRSA) Bureau of Health Professions developed by Congress in 1971 under Title XII of the Public Health Act [13]. The mission of Southwestern AHEC is “opening doors to better health in underserved communities through education, outreach, and career” opportunities. Through these efforts they develop programming for primary care workforce that ultimately aims to address the health care disparities that are prevalent across people of different races, ethnicities and socioeconomic statuses [13]. There are 54 AHEC programs across the nation with 250 centers that operate in almost every state. These programs work with a variety of professions including medical schools, nursing and allied health schools to help improve the quality of care in underserved and underrepresented populations. As part of the partnership with Southwestern AHEC, students were trained on how to better serve the homeless population by participating in Community Based Education and Training modules specific to working with vulnerable populations. Throughout the visits to the emergency shelter, students were accompanied by the executive director and the program director of Southwestern AHEC. They were able to support the students throughout the combined visits and provided resources to better enhance the resources offered to the homeless shelter based on the responses of the participants at the emergency shelter and a debriefing of the occupational therapy students.
Results
The above methods provided the students with the knowledge and experience to gather the necessary resources to initiate program development at the emergency shelter. Results of the assessment enabled the students to identify various healthcare needs of the individuals (Table 1). These results, however, were not deemed to be of priority to the residents because it did not align with information gained during conversations with the residents highlighting the most prominent needs based on findings revealed during weekly visits to the emergency shelter. From these results, the students adapted the intervention implementation plans with assistance from the representatives from Southwestern AHEC, resulting in the provision of the resident’s desired resources.
Results from the modified version of the AHEC Collegiate Health Service Corps Needs Assessment
Results from the modified version of the AHEC Collegiate Health Service Corps Needs Assessment
The residents indicated a need for reliable information on local transportation, electronic benefit transfer (EBT) card vendors, warming shelters, library resources, food pantries, map of the local area, available exercise options, leisure benefits, and routine making. After completing the eight visits, it was concluded that the instrumental activities of daily living resources mentioned above were of top priority to the residents as this point in time. The information gathered through the informal conversations led to the compilation of resources into a concise resource poster.
The created resources addressed the stated needs of the residents and were displayed on a poster board to be kept at the emergency shelter. Local transportation was addressed through a map of the local bus route, in addition to a list of locations to acquire bus passes. A list of EBT card vendors were provided which provides information on locations the individuals can utilize benefits issued by state welfare departments. Information on nearby warming shelters was also provided, which included the locations and contact information and where to obtain additional information. Library resources were addressed through a handout that included the address and hours of the public library, in addition to information on using the library resources and walking directions from the shelter. A calendar of library events was also included for the upcoming months. The resource poster also included information on local food pantries and soup kitchens, consisting of the hours, addresses, contact information and additional resources provided by each site. A map of the area was provided in the center of the resource poster with a legend of important locations, such as the library, police station, train station, and post offices. In addition to resources of the local area, information related to health and wellness was also provided, including the topics of exercise, leisure, and routines. The exercise resource included seven simple exercises that can be incorporated in the residents’ daily routine at the emergency shelter. The topic of leisure was addressed through a handout which listed why leisure is important, how it is beneficial, and ways the residents can engage in leisure activities. Lastly, routine making was addressed on why routines are important in a person’s day and the benefits routines provide. Finally, a blank daily schedule was provided to assist residents in scheduling each day, with additional spaces for daily goals, priorities, and appointments.
Throughout the time at ES, the executive director and program director of Southwestern AHEC attended the eight-week sessions with the students to provide guidance and support on program development as well as allowing the students to reflect on each visit. Southwestern AHEC also conducted a resident survey (Table 2) at the end of the eight visits to provide the students with data regarding future visits and program development. Future program development will allow for programs to build upon the areas that the residents enjoyed as well as areas that they wanted more information.
Results of Emergency Shelter Resident Survey from AHEC (n = 3)
Results of Emergency Shelter Resident Survey from AHEC (n = 3)
The results are representative of the identified needs of those residing in the emergency shelter. Conversations with the participants assisting in developing trust and rapport. Weekly conversations provided the students with the necessary tools to develop needed materials that address the underlying concerns of the individuals.
Occupational therapists have a distinct role in addressing the unique needs of individuals to increase independence in meaningful occupations. Occupational therapy practitioners acknowledge the barriers to success including housing, leisure, transportation, education, skill-building, employment and more individuals who are homeless may encounter. Occupational therapy practitioners utilize task-analysis and the influence of one’s environment to adapt or modify activities for participation by each individual. Per the Occupational Therapy Code of Ethics and Ethics Standards occupational therapy practitioners have the responsibility to advocate to increase access to health services for persons in need as an effort to reduce or eliminate health disparities across populations [14]. Health disparities are defined as “difference in incidence, prevalence, morbidity, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups” [15]. The administered program provided the foundational needs for the residents as a baseline for future program developments.
Based on the students’ findings, occupational therapy practitioners have a distinct role in intervening with individuals experiencing homelessness. Through the students experiences it was found that socialization and leisure are necessary tools to bridge the gap between resident and student relationships. Leisure allowed the students to build rapport, gather data and develop resources based on the findings. The resources developed exemplified the foundations in which occupational therapy can intervene with individuals who are homeless. Continued research on a larger population would expand the possibilities of occupational therapy interventions.
Conflict of interest
None to report.