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C. Lloyd and H. Bassett
FEATURE ARTICLE
The role of occupational therapy
in working with the homeless population:
An assertive outreach approach
Chris Lloyd and Hazel Bassett
Abstract
The issue of homelessness has gained increasing attention in recent years. Many factors contribute to homelessness. A
recent move to address the complex needs of the homeless in Queensland was the establishment of Homeless Health
Outreach Teams. These are multidisciplinary teams that have a primary focus in mental health, and drug and alcohol
rehabilitation. The introduction of occupational therapists to the team has resulted in the need to be very clear about
their skills and knowledge. This article describes homelessness, the background to the Homeless Health Outreach Team,
before discussing the role of occupational therapy on this team.
Key words
Homelessness, occupational therapy, mental health, meaningful occupation
Reference
Lloyd, C. & Bassett, H. (2012). The role of occupational therapy in working with the homeless population: An assertive
outreach approach. New Zealand Journal of Occupational Therapy, 59(1), 18 – 23.
T
he problem of homelessness has received increasing
attention in recent years. The Queensland Health Homeless
Initiative Plan 2006-2009 was set up to target those who are at
risk of homelessness in addition to those who meet the adopted
definition of homelessness (Queensland Health, 2007). There are
three categories of homelessness. This includes people without
conventional accommodation who are considered primary
homeless since they may be living rough on the streets, sleeping in
parks, squatting in derelict buildings, or using cars for temporary
shelter. The secondary homeless are those who frequently move
from one form of temporary shelter to another. For example,
emergency accommodation such as, hostels for the homeless or
night shelters, teenagers staying in youth refuges, women and
children escaping from domestic violence by staying in women’s
refuges, people residing temporarily with other families because
they have no accommodation of their own, and those using
boarding houses on an occasional or intermittent basis. Finally,
tertiary homeless are people who live in boarding houses on a
medium to long-term basis (Chamberlain & MacKenzie, 1992).
It was envisaged that the implementation of this plan would
improve the health outcomes for people subject to homelessness
by responding effectively and consistently to their identified
health needs.
According to the Commonwealth of Australia (2008), every night
around 105,000 people are homeless. The rate of rough sleepers
per 100,000 people is highest in the Northern Territory (75 per
10,000), followed by Queensland (13 per 10,000), and Western
18
Australia (12 per 10,000). On census night, the Australian Bureau
of Statistics provides a snapshot of people who are experiencing
homelessness by randomly counting rough sleepers and people in
specialist homeless services. Of those, 56% were men and 44%
were women. Interestingly, the difference increased to 60% men
for people over the age of 35 years. More men sleep rough and
live in boarding houses than women, and furthermore, family
homelessness, that is women with dependent children, increased
by 33% in the last five years (Commonwealth of Australia, 2008).
New Zealand lacks consistent data on the demographic profile of
its homeless population making it difficult to identify the housing
needs of the homeless and potentially homeless (Richards, 2009).
Corresponding author:
Dr Chris Lloyd Behavioural Basis of Health
Griffith University, Gold Coast Campus
Southport 4215
Australia
Email: [email protected]
Hazel Bassett MMedSci
Team Leader, Homeless Health Outreach Team
Ashmore Clinic
Queensland
New Zealand Journal of Occupational Therapy
Volume 59
No 1
The role of occupational therapy in working with the homeless population: An assertive outreach approach
However, it is likely the demographic profile conforms to other
western countries. According to Richards (2009), New Zealand
is in a position to address the basic need for shelter of its people,
regardless of age, gender, ethnic origin, religion or sexuality. At
present, there is no single Government department that has a
statutory responsibility for the homeless or for coordinating
services. It has been found that homelessness has a low profile as
a political issue (Richards, 2004).
There are many causes of homelessness. People who are at risk of
homelessness tend to face many difficulties, for example, domestic
and family violence, mental health problems, drug and alcohol
addiction, and poverty. When faced with social pressure such as
job loss, eviction, poor health, or relationship breakdown, people
without support, skills, or personal resilience, or who have limited
capacity due to their age or disability, may become homeless.
With limited resources, it is likely these vulnerable people will
remain homeless for a long period of time (Commonwealth of
Australia, 2008).
Homelessness has a direct impact on health. Homeless people,
particularly rough sleepers, have a higher rate of serious morbidity
compared to the general population. They tend to experience a
range of health problems including, infections, inflammatory
skin conditions, skin infestations, respiratory illness, physical
trauma, adverse effects of illicit drugs, and/or mental health
issues (Wright & Tomkins, 2006). They are also responsible for a
disproportionate use of judicial, social and health care resources.
Often the only health care that homeless people receive is through
the emergency department in a hospital (Turnbull, Muckle, &
Masters, 2007).
The history of occupational therapy is grounded in the
relationship between health and occupation (Finlay, 2004).
Occupational therapists address occupational performance areas
related to productive activities such as work, activities of daily
living, socialization, and leisure (Barnekow & Pickens, 2011).
People who are homeless face many social and economic barriers
that impact on their ability to fully engage in occupations in the
community. They are excluded from many basic aspects of life
such as education, employment, housing, social networks, and
health care. Since survival becomes their main aim, meaningful
occupations are directed towards surviving on the streets. A
key goal of occupational therapy is to assist clients who feel
excluded, isolated, hopeless or worthless to once again become
a part of their social world by ensuring the client’s environment
and social networks are as supportive as possible (Finlay, 2004).
This approach is endorsed by mental health recovery and
empowerment-oriented frameworks which posit that increased
participation in meaningful occupations endorses health and
well-being, mainly through the development of a personal and
social identity (Eklund, 2011).
The homeless health outreach team
In Queensland, the Homeless Health Outreach Teams (HHOT)
are multidisciplinary teams, consisting of occupational therapy,
medical, nursing, social work, psychology, welfare, and alcohol
Volume 59
No 1
FEATURE ARTICLE
and drug clinicians. These teams have a primary focus in mental
health, alcohol, and drugs. They are encouraged to actively
work in partnership with other professionals including general
practitioners (GP), non-government organisations (NGO),
local councils and other government agencies, such as housing
and Centrelink (government pension scheme). The goal of the
team is to assist in the development of a holistic approach to
service delivery. A recovery approach is utilised in recognition
of the fact that clients have the greatest knowledge and expertise
regarding their needs and service requirements. A recovery
approach identifies personal goals and how best to achieve them
within a given situation. Initially, a comprehensive assessment
is undertaken before collaborating with the person to develop
an individual treatment plan. The service delivery model has
three key components: assertive outreach, case management, and
collaborative response (Queensland Health, 2007).
Assertive outreach
Assertive outreach is essential to reach and engage with clients
who are homeless. More importantly, it brings the service into
community settings including shelters, food vans, parks or other
homeless agencies. A primary case manager is allocated to each
client and with their consent, the case manager collaborates
with others service providers to ensure continuity of care and
comprehensive treatment. As health care needs and other
basic needs are often interrelated, co-ordination with other
service providers is essential. There has been an emphasis on
the development of networks and referral pathways between
Queensland Health, NGOs, and other service providers to reduce
barriers to service access.
The HHOT employs 20.5 multidisciplinary staff who work
extended hours to cover seven days per week, 365 days per year.
The regular day shift has a team of clinicians at work, while the
evenings and weekends are covered by two staff members. Each
day begins with intake. That is to say, new referrals are presented
to the team. Once a person is accepted for intervention, and
the preliminary assessment is completed, a case manager and a
backup person are appointed. During the week, work is often
organised around service provision e.g. crisis accommodation,
and sources of free food.
A person referred to the team, must meet criteria for primary
or secondary homelessness and has either a mental health
problem and/or a substance use issue. Common diagnoses
include depression, schizophrenia, substance use, bipolar affective
disorder or personality disorder. On average, the HHOT team has
approximately 46 referrals per month (Lloyd & Bassett, 2010). It
is recommended that service support should be provided as long
as required (Queensland Health, 2007). Many clients are only
eligible for a short period of time. Others, with more complex
needs, may be followed up for an extended period of time. Some
clients are transient and so are lost to follow up. If they are known
to be transients, information is readily accessible to other HHOTs
in Queensland and to other agencies and services throughout the
country. Approximately 60 clients are case managed, but others
who are not registered as service users can be seen at the assertive
New Zealand Journal of Occupational Therapy
19
C. Lloyd and H. Bassett
FEATURE ARTICLE
outreach service in their community. Team members have a
primary responsibility for an average of five or six clients and
usually have responsibility for five or six more as back up.
Individual treatment plans identify the bio/psycho/social issues
that need to be addressed (see Table 1) as well as the client’s goals,
and the intervention strategies to achieve the goals. These plans
are drawn up by an occupational therapist in collaboration with
clients.
Occupational therapy role with the homeless
There is an unmet need for occupational therapists working
with the homeless and those who do, face multiple challenges
(Grandisson, Mitchell-Carvalho, Tang, & Korner-Bitensky, 2009).
The role has been addressed in a number of occupational therapy
Journals. For the most part, these articles have addressed the
perspectives of occupational therapists working in homeless
shelters (Griner, 2006; Herzberg, Ray, & Swenson Miller, 2006;
Munoz, Dix, & Reichenbach, 2006; Schultz-Krohn, 2004;
Tryssenaar, Jones, & Lee, 1999). Little has been published about
the role of occupational therapy working with the homeless
using an assertive community treatment model (Lloyd &
Bassett, 2010; Murtagh, Lloyd, & Bassett, 2010). The Assertive
Community Treatment Model focuses on providing intensive
case management within the client’s own environment (Krupa
et al., 2004). The literature, which is mostly from the USA,
Canada and UK, has also addressed employment interventions
(Kannenberg & Boyer, 1997), independent living skills (Davis
& Kutter, 1998; Helfrich & Fogg, 2007), the Model of Human
Occupation (Kavanagh & Fares, 1995), Occupational Adaptation
(Johnson, 2006), needs assessment (Finlayson, Baker, Rodman, &
Herzberg, 2002), functional needs of homeless people (Mosby,
1996), student fieldwork (Heubner & Tryssenaar, 1996; Totter &
Pratt, 2001), goal setting (Scultz-Krohn, Drnek, & Powell, 2006),
and assessing the occupational performance priorities of people
who are homeless (Munoz, Garcia, Lisak, & Reichenbach, 2006).
What is notable about the literature is that it predominantly
deals with occupational therapists working in homeless shelters.
Evident in the American literature, this has meant that there was
little information available to guide an occupational therapist
working with an assertive outreach team. Grandisson et al. (2009)
argued that occupational therapists have a unique approach to
the provision of client-centred care. Developing a role for
occupational therapy with persons who are homeless requires
an understanding of their individual needs and occupational
performance issues.
Table 1
Team Treatment Plan
Issue
Objectives
Ways this will be achieved
Medication
Currently on a depot. She has a previous
history of non compliance and becomes
unwell when not medicated. She benefits
from fortnightly depot injections to keep her
mental state stable.
To continue with fortnightly administration of
depot medication.
To be aware of early warning signs.
Fortnightly appointments with HHOT to
receive depot injection.
Develop a list of early warning signs and
look at a relapse prevention plan.
Weight management
To weigh her every fortnight when she
receives her depot injection so we can
monitor any weight gain.
Referral to a local walking group.
Referral to a local gym.
HHOT clinicians to take scales to depot
appointments to weigh her.
Monitor any increase in weight.
Accompany her to the gym to provide
support.
Health promotion
To provide her with ongoing education
around healthy eating and physical activity.
Ongoing education around the importance of
maintaining a healthy lifestyle.
Assist her in getting motivated to participate
further in activities such as walking on a
regular basis.
Goals
Assist her to develop a list of goals.
To support her in working towards achieving
the short and long term goals she has set
for herself.
Regular review of goals.
Evaluate progress every three months.
Monitoring m/s and risk
To continue to monitor her m/s and risk
during routine appointments.
Monitor m/s, assess for early warning signs.
Ongoing monitoring of risk at each
appointment.
20
New Zealand Journal of Occupational Therapy
Volume 59
No 1
The role of occupational therapy in working with the homeless population: An assertive outreach approach
Role of occupational therapists in the team
Occupational therapists in HHOT work in a variety of both
generic and occupational therapy specific roles. Like other
members of the team, they complete consumer assessments, risk
assessments, mental state examinations, formulate a recovery plan
(see Table 2) and engage clients in case management. In a more
discipline specific role, occupational therapists also complete
functional and financial assessments, which are followed up
by making recommendations to the Department of Housing
regarding an individual’s ability to maintain a tenancy and/or
regarding supports that may be required. Occupational therapy
functional assessments may include a combination of interview,
practical tasks, and standardized assessments to assist with
identifying meaningful occupational roles. The identified roles
may include those with which the client is currently engaged and/
or those the client has identified as being important for the future.
Occupational therapists also assist a client to re-establish major
life roles such as family roles, including parenting. An example
FEATURE ARTICLE
of this would be to restore contact with a child by assisting with
access and encouraging parenting skills. If a client who has
been homeless is allocated accommodation by the Department
of Housing, then an occupational therapist may be called in to
assist the person to acquire basic house management skills. For
example, activities of daily living such as personal care, budgeting,
shopping, food preparation, cooking, leisure time planning,
keeping the house clean and tidy, and using a washing machine.
People who have experienced homelessness benefit from this
input.
In the belief that purposeful use of time and energy, gives life
meaning, occupational therapists working with the homeless aim
to assist clients to maximize strengths and build skills to participate
effectively in everyday activities. Furthermore, engaging in
meaningful occupations helps clients to improve their mental
health and overall sense of wellbeing. Of importance when
dealing with people who have been marginalized and excluded
is a focus on assisting them to establish routines, and to find
Table 2
Mental Health Services Recovery Plan
Ways in which staff/others help me to achieve
my objectives
Issue
Objectives
Contact with children
Short term:
To have fortnightly phone contact with my two
oldest children who live in NSW.
Fortnightly p/cs when I top up my phone.
Long term: To work towards weekend overnight
stays with my two youngest children within the
next 12 months.
To visit my oldest two children who live in NSW
within the next 12 months.
Continue with fortnightly contact with children to
show commitment.
Discuss with Aunty and arrange overnight stays.
Purchase a sofa bed for the children to sleep on
when staying over.
Save money towards the trip to NSW.
Discuss with children’s legal guardian.
Work towards a specific date.
Household items
Short term: To purchase further items for my unit,
including a sofa bed and a rug.
Save money.
Apply for a Centrelink loan when eligible.
Health
Short term: To get my weight checked once a
fortnight when I receive my depot to monitor
weight gain.
HHOT clinician who administers the depot are to
ensure they take the scales to check weight.
To make an appointment with the women’s health
clinic to get a complete woman’s health check up
within the next three months.
HHOT case manager to assist in making the
appointment and providing transport for the first
appointment for support.
Long term: To give up drinking alcohol so I can
work towards increasing contact with my children,
save money and be healthier.
To continue to liaise with HHOT staff regarding
same. Wants to do this on her own terms.
Discuss with GP medications to assist with
cravings.
To give up smoking.
Discuss with GP.
Short term and long term:
To save $20.00 each fortnight.
Stick to a budget.
Do not withdraw money from savings.
Finances
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New Zealand Journal of Occupational Therapy
21
C. Lloyd and H. Bassett
FEATURE ARTICLE
satisfaction in carrying out daily occupations. These tasks draw
upon core occupational therapy skills and models of practice such
as the Model of Human Occupation (Kielhofner & Burke, 1985).
Reflection on outcomes
Establishing the role of occupational therapy within the team
has been an ongoing challenge. For instance, staff attendance at
outreach venues requires co-ordination and flexibility, particularly
when a client presents as unwell and requires extra input to assess
the problem. Models of practice that include the environment
require occupational therapists to consider the impact of the
environment with reference to meaningful occupations. There
is also an element of risk involved as outreach occurs both early
in the morning and late at night. This can lead to issues arising
around intoxication, aggression, and other unknown elements
that may impact upon the safety of team members.
Furthermore, working shift work is a relatively new expectation
for occupational therapists. In using generic mental health skills,
they also have to try and maintain their identity as occupational
therapists and to demonstrate the relevance of their discipline
specific skills. Overall, occupational therapists on the team have
risen to these challenges while demonstrating the unique value
of occupational therapy intervention for this client group, to the
other team members.
Lloyd, Bassett, and King (2010) conducted a study to determine
whether the HHOTs could operate within an established
framework. They found that the teams operated in the middle
range on the fidelity measure with higher fidelity in human
resources and nature of services such as, developing community
skills in vivo rather than in an office, in organisational boundaries.
This provided the background for other research projects on
specific aspects of treatment for clients such as, examining pet
ownership among the homeless (Slatter, Lloyd, & King, in press).
It would be of interest to survey other teams who work with
homeless clients to find out whether they employ occupational
therapists and, if they have a discipline specific focus.
Conclusion
Working with the homeless is an opportunity for occupational
therapists to develop their role in a relatively new field of practice.
The occupational therapy focus on function, purposeful activity,
life roles and the development of individual capacity lends
itself well to this specialised field. The authors contend that
occupational therapists have a key role to play in addressing the
functional needs of homeless people and assisting them to take
up meaningful occupational roles. The inclusion of occupational
therapists on this team has enabled a holistic approach to service
provision that has been of benefit to the people who access the
services. From a professional perspective, occupational therapists
working within the Homeless Health Teams have been able to
improve their generic skills while utilising occupational therapy
specific skills.
22
References
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F.A. Davis.
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homelessness: Issues of definition and meaning. Australian Journal of
Social Issues, 27(4), 274- 297.
Commonwealth of Australia. (2008). The road home. A national approach
to reducing homelessness. Canberra: Commonwealth of Australia.
Davis, J., & Kutter, C. J. (1998). Independent living skills and posttraumatic
stress disorder in women who are homeless: Implications for future
practice. American Journal of Occupational Therapy, 52(1), 39-44.
Eklund, M. (2011). Occupation and wellness. In: C. Brown & V. C. Stoffel
(Eds.), Occupational therapy in mental health: A vision for participation.
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Finlay, L. (2004). The practice of psychosocial occupational therapy, (3rd
ed.). Cheltenham, UK: Nelson Thornes.
Finlayson, M., Baker, M., Rodman, L., & Herzberg, G. (2002). The process
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Grandisson, M., Mitchell-Carvalho, M., Tang, V., & Korner-Bitensky, N.
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who are homeless. British Journal of Occupational Therapy, 72(11), 491498.
Griner, K. R. (2006). Helping the homeless: An occupational therapy
perspective. Occupational Therapy in Mental Health, 22(1), 49-61.
Helfrich, C. A., & Fogg, L. F. (2007). Outcomes of a life skills intervention
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Herzberg, G. L., Ray, S. A., & Swenson Miller, K. (2006). The status of
occupational therapy addressing the needs of people experiencing
homelessness. Occupational Therapy in Health Care, 20(3/4), 1-8.
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Krupa, T., Eastabrook, S., Beattie, P., Carriere, R., McIntyre, D., & Woodman,
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New Zealand Journal of Occupational Therapy
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The role of occupational therapy in working with the homeless population: An assertive outreach approach
Munoz, J. P., Garcia, T., Lisak, J., & Reichenbach, D. (2006). Assessing
the occupational performance priorities of people who are homeless.
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FEATURE ARTICLE
Slatter, J., Lloyd, C., & King, R. (in press). Homelessness and companion
animals: More than just a pet? British Journal of Occupational
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