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Co-Occurring Disorders and Homelessness

Integrated Services for Individuals with Co-Occurring Disorders Who Are Homeless

As with all individuals with co-occurring disorders, current evidence suggests that the most effective way to support and serve individuals with co-occurring disorders who are homeless is to provide support and services through integrated systems of care. Individuals who are homeless may seek treatment in shelters, emergency rooms, the criminal justice system, substance abuse systems, or mental health systems. All of those systems may participate in integration efforts to provide effective treatment for co-occurring disorders.

Integrated service teams are especially important

Individuals referred to behavioral health services by practitioners in other agencies such as homeless or primary care settings can have low rates of follow through.

A key piece to effective treatment for persons who are homeless is housing. Safe and stable housing is the centerpiece of a comprehensive, integrated and seamless approach to prevention, treatment and ongoing recovery. A study of integrated co-occurring disorder services and housing in Philadelphia's Housing First programs demonstrated that of individuals who were housed and receiving services, 79 percent showed improvement in mental health and 57 percent showed improvement in substance abuse. Of those individuals who received services but not housing, 20 percent showed improvement in mental health and 15 percent showed improvement in substance abuse.

Examples of integrated service models

Health Care for the Homeless, from the Federal Health Resources and Services Administration, funds community programs throughout the country that promote comprehensive, integrated service delivery. Health Care for the Homeless programs often employ interdisciplinary teams of practitioners that provide services such as:

  • Outreach and case management
  • Substance abuse services
  • Emergency care
  • Mental health care services
  • Primary care services
  • Housing assistance
  • Employment assistance
  • Benefits assistance

Boston Health Care for the Homeless Program's Street Team provides integrated care for chronically homeless individuals. Boston's program estimates that approximately 90 percent of its chronically homeless population has a substance use disorder, and about 60 percent have a mental illness. A key component of Boston's service delivery model is the co-location of primary care and behavioral health practitioners. Mental health, substance abuse, and medical personnel work side-by-side:

  • On the streets
  • In a hospital clinic
  • In a medical respite care program
  • Through "house calls" to individuals placed in supportive housing programs

Each individual has one treatment plan with both behavioral and medical elements. Employing integrated care during outreach has been a successful approach for this program.

Homeless Health Care Los Angeles also uses a multidisciplinary, team treatment approach to provide a continuum of mental health care, substance abuse care, physical health care and social services for persons who are homeless and have co-occurring disorders. This program provides a comprehensive assessment of each individual's mental and physical health needs, substance abuse needs, and personal goals and desires. Staff then creates an integrated plan for individualized treatment, providing services for substance abuse and mental health simultaneously. Staff update the treatment plan every 90 days.

Project Coming Home in Contra Costa County, California, provides scattered site permanent housing for chronically homeless individuals (approximately 80 percent have co-occurring disorders) using a housing first approach. The project uses Mobile Integrated Service Teams made up of staff from multiple mainstream and homeless agencies. The team provides:

  • Medical
  • Mental health
  • Substance abuse treatment
  • Support services in the individuals' homes

Individuals in the program may elect residential treatment at any time and their housing is maintained for them.

Resources and Links

  • Website provides detailed information on the organization's activities.

  • Website describing Homeless Health Care Los Angeles program, including how this agency provides a continuum of integrated services for persons with co-occurring disorders who are homeless.

  • This study examined the effectiveness of the Comprehensive, Continuous, Integrated System of Care (CCISC) model in addressing co-occurring mental health and substance use disorders among individuals who were homeless. Results demonstrated significant improvements in housing, employment, mental health, and substance use at 12-month follow-up. These results underscore the effectiveness of implementing evidence-based care.

  • A PowerPoint presentation about the program design, successes, and challenges of two Housing First programs in Philadelphia.

  • The Homelessness Resource Center (HRC) is an interactive community of providers, consumers, policymakers, researchers, and public agencies at federal, state, and local levels. HRC participants share state-of-the art knowledge and promising practices to prevent and end homelessness through training and technical assistance, publications and materials, on-line learning opportunities and network and collaboration.

  • The Center Homelessness Activities Branch (CHAB) issues grants and sponsors other projects to advance the field. Additionally, CHAB provides grantees and the field with state-of-the-art technical assistance to help individuals and entities to address homelessness and co-occurring disorders (COD. Through its website, CHAB hopes to help build and support a learning community that brings together stakeholders to advance and improve the care of persons with or at risk for homelessness and/or COD.

  • Settings outside the substance abuse and mental health systems, or settings where service missions do not include a primary focus on COD, are the focus of this overview paper. Primary health, public safety and criminal justice, and social service settings, where persons with COD are likely to be seen, are highlighted. These settings should be prepared to identify and effectively respond to persons with COD. The use of specialized techniques appropriate to these settings can increase the likelihood that the person with COD will access needed treatment.

  • This in-depth report provides a review of data related to risk factors for HIV related to homelessness and mental illness. It includes a discussion of assessing HIV risk and reducing risk through prevention. The third section of the report is focused on adapting policy and practice, including training and educating staff and clients, managing client care, and managing HIV testing.