BACKGROUND: People experiencing homelessness (PEH) commonly experience “tri-morbidity,” whereby the effects of physical illness, mental illness, and substance use disorder combine to produce complex healthcare needs. Tiny home villages, or communities comprised of dwellings that are 400-square feet or smaller, have emerged in the U.S. as one option to bridge the gap between living on the street and temporary or permanent shelter. However, whether these communities have been successful in connecting PEH to health services has not been well explored. House of Hope Community Development Corporation sought recommendations for health care services organization and delivery at ECHO Village, a temporary tiny home village in Rhode Island, to meet the health care needs of its clients. AIMS: (1) To characterize barriers and opportunities to engage PEH in care from the perspective of health care providers using the CDC’s 6 Guiding Principles to a Trauma Informed Approach; (2) to assess the health care priorities and barriers and facilitators to care from the perspective of PEH using the Behavioral Model for Vulnerable Populations, and (3) to inform recommendations for health services delivery for ECHO Village and for similar homelessness service settings more broadly. METHODS: Literature was reviewed on evidence-based practices for providing health care to PEH, tiny home villages for PEH, and emergency, temporary housing. A matrix was developed to collect and organize descriptive data to select a comparison tiny home village. In Aim 1, 18 in-depth interviews were conducted with health care providers and other key informants in Rhode Island and at Avivo Village, a tiny home village for PEH in Minneapolis, Minnesota, to characterize barriers and opportunities to engage PEH in health care. In Aim 2, 10 in-depth interviews with Avivo Village residents were conducted to identify health care priorities, barriers, and facilitators to care. The 6 Guiding Principles to a Trauma-Informed Approach and the Behavioral Model were used to create initial coding frameworks for provider and resident interviews, respectively. Through an iterative process, codes were refined to aggregate data into patterns of meaning, emerging themes were revealed, and similarities and differences were identified through consensus coding for interpretation purposes. The Behavioral Model was used to assess the role of predisposing, enabling, and needs factors in health services utilization through a structured survey of 93 adults aged ≥18 experiencing homelessness in Rhode Island. Associations between subsistence difficulty and five health utilization outcomes using bivariate tests of survey data were evaluated. Binomial logistic regressions were run to explore the effects of predictor variables on these outcomes. RESULTS: Thematic analysis revealed that the tiny home village setting could facilitate the care of PEH by (1) overcoming many of the common barriers to receiving care for people who had been excluded from traditional shelters and other critical services, (2) affording a sense of safety and security for PEH, and (3) allowing PEH time and space to gain stability to focus on self-identified goals at their own pace. The importance of patient empowerment, peer support, mixed communities in which people in various stages of recovery live together, and non-judgmental providers also emerged as facilitators of care. Quantitative results showed that subsistence difficulty predicted going without needed care for the past 12 months at p <.05. Adjustment for potential confounders did not change our inferences. CONCLUSION: Several promising practices exist for health service organization and delivery in the tiny home village setting that can be replicated, scaled, and sustained regardless of model or service mix. Given the significant barriers to accessing healthcare faced by PEH, the tiny home village setting can serve as an effective engagement point for PEH, particularly for those averse to traditional shelters or care settings. / 2024-07-05T00:00:00Z

Homelessness represents a significant and multifaceted challenge that profoundly impacts numerous individuals on a global scale. It is noteworthy that approximately one third of the homeless population comprises women, and alarmingly, roughly 90% of single parents experiencing homelessness are women. Moreover, among women facing homelessness, mental health issues and substance abuse are disproportionately prevalent, as has been observed in recent research by O'Campo and colleagues (2023). The factors leading to homelessness among women are intricate and diverse, as evidenced by scholarly investigations. Vulnerability to violence, exploitation, and marginalization, coupled with limited access to resources and essential life skills, are among the prominent underlying reasons (Milaney et al., 2020). Considering these critical challenges, the development of effective interventions becomes imperative. Addressing the issue of inadequate life skills necessitated the creation of a specialized program, spearheaded by occupational therapists (OT). This life skills program was meticulously crafted following an extensive review of the existing literature and thoughtfully incorporated elements from previous successful initiatives, such as the Housing First Program (HFP) and the Supporting Many for Residential Transition (SMART) program. The proposed occupational therapy (OT)-led life skills program is set to be implemented at a transitional living facility under the auspices of the Father Bills & Mainspring (FBMS) organization, situated in the Boston, MA area. This program will be twelve weeks and specifically designed to cater to women between the ages of 18 and 30, who currently reside within the transitional living facility. The program's core emphasis will be on developing essential living skills, encompassing independent living proficiencies, as well as employment readiness capabilities. The overarching objective of this intervention is to equip the participants with essential skills, empowering them to secure gainful employment and successfully transition into self-sufficient housing arrangements. Upon the conclusion of the twelve-week program, it is predicted that the participants will acquire profound knowledge and skills concerning independent living and employment. These proficiencies will be subject to evaluation through the administration of a comprehensive questionnaire. Moreover, the prospective long-term outcomes of this program encompass the participants' capacity to maintain sustainable arrangements for independent living and pursue meaningful and lasting employment opportunities. If the efficacy of this program attains the anticipated positive outcomes, the overarching objective shall entail its integration as a permanent fixture within the institutional framework of the FBMS organization. Furthermore, its propagation across additional homelessness organizations in the area of Boston, MA, would be a desired outcome, thus amplifying its societal impact and fostering greater support for those facing housing instability.

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Importance – The homeless face higher rates of morbidity and mortality than the general population, and have lower rates of end-of-life care planning. An effective and sustainable intervention, to provide living wills and durable power of attorney, is required to protect the autonomy of a vulnerable population. Objective – To determine if medical student-led 1:1 counseling is as effective as social worker-led counseling as reported in the literature, determined by rate of advanced directive completion. Design – A focus groups and educational sessions on EOL care and ADs were conducted at 2 shelters, after which participants were offered the opportunity to sign up for a 1:1 counseling session with a medical student volunteer. Rates of sign-ups and completion were recorded. Setting – 2 North Philadelphia homeless shelters, requiring either an Axis I or current substance abuse diagnosis for residence. Participants – A convenience sample of 20 homeless men were approached; 10 enrolled in the study. Interventions – Educational sessions, focus groups, and 1:1 AD completion counseling sessions Main Outcomes – Interest in and completion of an advanced directive. Results – 9 participants signed up to complete ADs after an informational session. At the conclusion of the study, 8 of them (88.8%) completed ADs. 40% of the total participants completed an AD. Conclusions – Similar rates of advanced directive completion were achieved with the student-led intervention compared to a previous intervention in the literature. Further study with a larger sample including homeless women should be conducted to provide a generalized conclusion. / Urban Bioethics

Grounded theory research was conducted with twenty-four male and female emergency shelter operators (alternatively known as caseworkers) from three different shelters in a large Canadian city: The Open Arms, Good Samaritan and Rescue Mission. Drawing on the experiences of those working in non-profit ‘homeless’ shelters, and based on the sociological concept of ‘dirty work,’ this study describes why caseworkers take on this kind of work, how they make sense of it, and what they themselves get out of it. This research reveals a complex picture of frontline emergency casework that others see as objectionable, dangerous and tainted is described by informants with a sense of job satisfaction, dignity, collective esteem and pride. Moreover, it illuminates the ways in which individuals and occupational groups reframe and subjectively construct meanings about what it means to be involved in ‘dirty work’ such that it is regarded positively and as ‘good work’. Because caseworkers deal in difficult emotions, they must learn to perform a balancing act between professional decorum and expressed concern. The ways that caseworkers are supposed to perceive their roles are governed by a set of unwritten norms and rules that normalize and renarrate disruptive and abnormal situations of a caseworker being humiliated, berated, verbally and physically attacked and by which they accept this as normal and therefore morally acceptable. It was typical for frontline caseworkers, working in non-profit shelters, to emphasize the relational and affectual rewards of the job as a compensation for its low pay and dirty ‘particulars,’ which meets the expectations, self-conceptions and values they hold themselves to be as caring and compassionate workers. They accomplish this by redirecting attention to the more dignifying aspects of their jobs and by identifying strongly with both their occupations and the collective identity of their occupational culture. This research further underscores both the importance of understanding the interpretive processes of meaning-making and the social construction of ‘dirt’. / Thesis / Master of Arts (MA)