the status of occupational therapy: addressing the needs of people experiencing homelessness
TRANSCRIPT
OVERVIEW
The Status of Occupational Therapy:Addressing the Needs
of People Experiencing Homelessness
Georgiana L. Herzberg, PhD, OTR/LSharon A. Ray, ScD, OTR/L
Kathleen Swenson Miller, PhD, OTR/L
SUMMARY. This paper discusses the move of occupational therapypractitioners towards providing services for people who are homeless,presents the results of an internet-based survey of assessment tools usedwith this population, and provides an overview of this volume’s papers
Georgiana L. Herzberg is Retired, Professor of Occupational Therapy, Nova South-eastern University, Ft. Lauderdale, FL. Sharon A. Ray is Assistant Professor, Depart-ment of Occupational Therapy, Tufts University, Medford, MA. Kathleen SwensonMiller is Assistant Professor, Department of Occupational Therapy, Jefferson Collegeof Health Professions, Thomas Jefferson University, Philadelphia, PA.
Address correspondence to: Georgiana Herzberg (E-mail: [email protected]).
[Haworth co-indexing entry note]: “The Status of Occupational Therapy: Addressing the Needs of PeopleExperiencing Homelessness.” Herzberg, Georgiana L., Sharon A. Ray, and Kathleen Swenson Miller.Co-published simultaneously in Occupational Therapy in Health Care (The Haworth Press, Inc.) Vol. 20,No. 3/4, 2006, pp. 1-8; and: Homelessness in America: Perspectives, Characterizations, and Considerationsfor Occupational Therapy (ed: Kathleen Swenson Miller, Georgiana L. Herzberg, and Sharon A. Ray) TheHaworth Press, Inc., 2006, pp. 1-8. Single or multiple copies of this article are available for a fee from TheHaworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address:[email protected]].
Available online at http://othc.haworthpress.com© 2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J003v20n03_01 1
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while discussing the current status of occupational therapy interven-tions. doi:10.1300/J003v20n03_01 [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com>©2006 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Assessment, intervention, homeless
The purpose of this publication is to codify the current thinking of oc-cupational therapy practitioners about interventions with people who arehomeless and stimulate discussion about future directions. Homeless-ness isnotunusualasanepisodic, transitional,orchronicevent inmanyofourclients’ lives.Peoplewhoarehomelessexperiencehealthproblemsatmore thantwice therateofpersons instablehousing(Gelberg&Arangua,2001).Forty-twopercentof thispopulationreportactivity limitationsand46% havechronichealthconditionssuch as arthritis, diabetes,highbloodpressure,orcancer (NationalRehabilitationHospitalCenter forHealth&Disability Research, 2002; Burt, 2001). Women who are homeless expe-rience poorer physical health than women in the general population andnearly 88% have a history of severe physical violence and/or sexual as-sault (Bassuk, Weinreb, Buckner, Browne, Salomon, & Bassuk, 1996).Families are now the fastest growing segment of this population and ac-count for 41% of homeless people (U. S. Conference of Mayors, 2005).Their children have very high rates of acute illness, and are at increasedrisk for developmental delays, learning disabilities, emotional problems,cognitive impairments and behavioral problems (Better Homes Fund,1999).Peoplewith severeandpersistentmental illnessesareoftencaughtin a spiral of downward economics that may include episodic, transi-tional, or chronic homelessness. Supplemental Security Income (SSI) isno longer a help in keeping people with mental or physical disabilitiesfrom becoming homeless because, in 2002, the average national rent ex-ceeded the amount of income available for recipients of this federal pro-gram (Consortium for Citizens with Disabilities Housing Task Force,2003). Persons with chronic health conditions and disabilities comprisepopulations with whom occupational therapy practitioners traditionallywork so it becomes logical to also provide services in shelters and agen-cies that serve people who are homeless.
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ASSESSMENTS USED BY OCCUPATIONAL THERAPISTSIN HOMELESS SHELTERS
In early2005, theco-editorsof thisbodyof work conductedasurvey ofthe assessment tools occupational therapy practitioners use with personswho are homeless. Via the Internet, print media, and personal contacts,werecruitedavolunteersampleofpractitionersworkingwithpeoplewhoare homeless. Requests for information appeared on three AOTA list-servs (Community, Mental Health, and Program Director), in a privatelistserv (OT and Underserved Populations at YahooGroups.com), and inthe on-line and print versions of OT Advance. No pediatric listservs werespecifically contacted. Respondents provided contact information, cre-dential (i.e., OT, OTA, other), current professional role, and indication ifthey worked with homeless adults, children, and/or families. Respon-dents thencompletedasurveyofopen-endedandforcedchoicequestionsto systematically provide information regarding (1) the use of both stan-dardized tools and non-standardized/therapist-developed assessmenttools, (2) the purpose for which each tool was used, (3) level of satisfac-tion with each identified tool, and (4) in the case of therapist-developedtools, if the person would be willing to share his/her assessment tool.
A totalof43 respondents (41OT,2OTA) from19states in theUS (AL,CA, CT, FL, IN, KY, LA, MI, MN, MT, NE, NM, NY, SD, TN, TX, VA,WA, and WI) and four countries (Canada, England, India, and Ireland)identified with an e-mail address. An additional four people (OT) pro-vidednoe-mailaddressandappeared toworkwith twoof the respondentsidentified by e-mail addresses. Some respondents reported overlappingroles resulting in a role-defined total (n = 52) of four researchers, 32 clini-cians, nine faculty members with academic responsibilities, two field-work coordinators, and five OT students. This group of people identifiedworking in a total (n = 50) of 39 programs for adults, two programs foryouth, four programs for children, and five programs for families. Thelimited responses related to work with children and families may reflectour recruitmentmethod.For theadultpopulation, therewere32reportsofthe use of standardized assessments and 27 reports of the use of thera-pist-developed/non-standardized tools. See Table 1 for the most fre-quently used standardized assessments with adults and the purposes forwhich they are used.
Table 2 identifies single program use of standardized tools and Table 3identifies the emphasis of therapist-developed, non-standardized tools incurrent use.
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The respondents who identified as working with the two youth pro-grams reported use of the Adolescent Sensory Profile and an interestchecklist. The assessment tools used in one or more of the four children’sprograms were the Sensory Profile, Developmental Test of Visual MotorIntegration (VMI), and/or therapist-developed tools. The five programsfor families reported using one or more of the following: OccupationalSelf-Assessment (OSA), Kohlman Evaluation of Living Skills (KELS),
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TABLE 1. Adult Program Most Frequently Used Standardized AssessmentTools and Their Purposes
Assessment Tool (frequency) Purpose
KELS (16) Daily living, self care, home management
Community safety & money management
Client needs for skills in independent living
ACL (12) Cognitive ability related to work, ADLs, IADLs,
Interpersonal communication
Cognitive level of functioning
Cognitive abilities and expectations of performance
Problem solving abilities
Level of supervision required
How to teach clients with lower cognitive function
COPM (11) Determining client goals
Developing relevant client goals
Client point of view about how functioning
Client point of view about areas of dysfunction
Determining client's view of important occupations
Prioritizing interventions
Building collaboration with client
OPHI-II (2) Data to help plan life projects
Quality of Life Rating Scale (2)* Important aspects of client's life and satisfaction
Note: n = 39 programs; All other standardized tools (n = 14 tools) were reported as used by only oneprogram.Allen Cognitive Levels (ACL), Canadian Occupational Performance Measure (COPM), Kohlman Evalua-tion of Living Skills (KELS), Occupational Performance History Interview-second version (OPHI-II)Respondents were not specific regarding which of the many standardized quality of life rating scales (mar-keted for use with people with specific kinds of disabilities) were used.
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Herzberg, Ray, and Swenson Miller 5
TABLE 2. Standardized Assessment Tools Reported Used by a SingleProgram
Beck Depression Inventory
Occupational Self Assessment (OSA)
Nine Hole Peg Test
Adult Sensory Profile
Role Checklist
Functional Independence Measure (FIM)
Mini-Mental Status Examination (MMSE)
Rosenberg Self Esteem Scale
Barriers to Employment Success Scale
Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS)
Bay Area Functional Performance Evaluation (BAFPE)
Ways of Coping
Contextual Memory Test
TABLE 3. Nonstandard or Therapist-Developed Tools Reported
ADL retraining (hygiene, safety, meal prep)
Center Developed questionnaires/Databases
Checklist of personal activities
Client interview
Client Self Assessment
Functional Assessment of Housing Needs
Functional Capacity Screen
Goal achievement scale adapted
Home safety assessment
Info taken from various tools (e.g., Board of Scientific Internet Tools)
Inventory of life skills
Living skills books (anger, stress, time management, money management, etc.)
OT Group Assessment
Screening of ADLs, domestic, & community skills
Screening of cognitive, vision, psychosocial performance, client goals, existing supports
Screening of self care, home management, upper extremity function
Self assessment of self care and productivity
Questionnaire related to Quality of Life Scale
Note: n = 27 responses from 21 programs
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Canadian Occupational Performance Measure (COPM), Allen’s Cogni-tive Levels (ACL), and/or therapist-developed tools.
Both the standardized and non-standardized tools reflect a clear con-cern for gathering information that allows collaborative development ofclient-centered interventions. The assessment tools also reflect a holisticconcern for the contextual and performance factors that affect participa-tion, allowing identification of strengths as well as challenges. The im-portance of client goals and priorities was readily apparent in the data andemphasized occupational performance and participation.
BEGINNING STAGES OF BUILDING A BODYOF LITERATURE
We have a sound beginning in documenting the work of occupationaltherapists with persons who are homeless, but the truth is that this is but abeginning. We are in the infant stages of creating a body of literature onhow to collaborate with people who are homeless, to facilitate their occu-pational performance and their full participation in society. In these pa-pers you will find that there is not a unified approach in assessment, inintervention, or in use of theory to help guide either assessment or inter-vention despite our clear emphasis on obtaining and using client input toguide interventions. These manuscripts do not reflect the age and gendermajority demographics of homelessness. Our over-inclusion of articlesreflectinginterventionswithchildren/youthandfamilies(insteadofadultmales who represent 41% of the population who are homeless accordingto the US Conference of Mayors, 2005), reflects the government fundingstream that allows occupational therapists to provide services for chil-dren. Such services can be reimbursed through the federal government’sHead Start, early intervention, or school-based programs (IDEA, 2004).The over-inclusionalso reflects,we believe,our profession’s current em-phasis on pediatric occupational therapy which accounts for 34% of allwork environments of AOTA members (AOTA Workforce TrendsSurvey, 2003).
This body of work illuminatesour current stage of trying to understandthe phenomena of homelessness and occupational therapy roles. Hope-fully, it will provide a baseline for dialog on our future directions, andstimulate healthy debate about–and interest in–an understanding of theoccupational performance issues of persons who are homeless, occupa-tional therapy practitioner roles, and evidence-based interventions thatsupport full participation by this population. There is a substantial need
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for additional research focusing on outcomes measurement and onfunder-defined outcomes measurement as is elaborated in the systemsarticle by Livingston and Swenson-Miller in this publication.
This special volume provides an interface between occupational ther-apy philosophy, occupational therapy practice, research on issues ofhomelessness, and policy implications. In Articles 2 and 3, you will finddiscussion of the complex issues of homelessness and the systems ofavailable services. In articles 4 through 8, the phenomenon of homeless-ness is explored using different occupational therapy theories and per-spectives. Articles 9 through 12 include studies of occupational therapyassessments and interventions with persons who are homeless. You willread descriptions and research that increase understanding of how theo-retical models, assessment instruments, and/or program evaluation tech-niques are used with persons who are homeless. These articles provideinsights that can lead to societal inclusion, occupational participation,and social justice for this population.
We thank our guest editors for their thoughtful and insightful com-ments. Our guest editors are Laura Hansen, CEO of the Broward Coali-tion to End Homelessness, Ft. Lauderdale, FL; Kathleen Hagen,Educational Support Services, Nova Southeastern University, Ft. Laud-erdale, FL; Debbie Perry, Director of Homeless Programs, HendersonMental Health Services, Ft. Lauderdale, FL; Dr. Susan Kusama, retiredoccupational therapy educator, St. Louis, MO; Dr. Susan Toth-Cohen,Associate Professor, Department of Occupational Therapy, Thomas Jef-fersonUniversity,Philadelphia,PA;andDr.KevinLyons,Directorof theCenter for Collaborative Research, Thomas Jefferson University, Phila-delphia, PA. We hope these articles will generate additional thinkingabout how participation is supported and generate new ideas on occupa-tional therapy roles that facilitate health and wellness and ensureclient-centered, culturally sensitive occupational therapy practice.
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Bassuk, E. L., Weinreb, L. F., Buckner, J. C., Browne, A., Salomon, A., & Bassuk, S. S.(1996). The characteristics and needs of sheltered homeless and low-income housedmothers. Journal of the American Medical Association, 276(8), 640-646.
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National Rehabilitation Hospital Center for Health & Disability Research (2002).Homeless and disabled: Focusing on the health and healthcare needs of an under-served population. Available at http://www.nrhrehab.org/documents/Research/brief_housing.pdf, Accessed 3/16/06.
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