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a Sheffield Institute for Studies on Ageing, University of Sheffield
Correspondence: Anthony M. Warnes, PhD, Sheffield Institute for Studies on Ageing, University of Sheffield, Community Sciences Centre, Northern General Hospital, Sheffield S5 7AU, U.K. E-mail: a.warnes{at}sheffield.ac.uk.
Decision Editor: Vernon L. Greene, PhD
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Abstract |
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 TOP Abstract The Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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Key Words: Homeless • Rehabilitation • Resettlement
The aim of this article is to assess the ways in which older homeless people can be helped to return to more conventional accommodation and lives. It draws on the experiences of Lancefield Street Center, an experimental multiservice program and hostel in London (England) for older people who were sleeping on the streets. The article begins with three concise reviews: of the problems and needs of older homeless people, of the recent development of policies and services for homeless people in the United Kingdom, the United States, and Australia, and of previous service innovations dedicated to the age group. A broad account of the achievements and lessons of the Lancefield Street experiment is followed by an analysis of the long-term accommodation outcomes for its residents. From this evidence, and the experience of a few related projects, the conclusions focus on the kinds of services and interventions that do make a difference to single older homeless people's lives.
Discussions of homeless people require terminological precision. In the United Kingdom, the term single homeless people distinguishes those who are not registered as homeless with local authority housing departments and, through a statutory obligation, thereby given priority access to public or "social" housing. Many have not approached a housing authority for help; some have been refused. Nearly all single homeless people either sleep in temporary or "direct access" hostels run by religious or voluntary organizations or are "rough sleepers," that is, they live on the streets, in shop and office doorways, at train stations and bus terminals, or in secluded locations such as abandoned buildings, cellars, disused cars, subway tunnels, and barns. The equivalent U.S. term for the latter is street people (Snow and Anderson 1993
).
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The Problems and Needs of Older Homeless People |
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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; Cohen, Ramirez, Teresi, Gallagher, and Sokolovsky 1997; Cohen and Sokolovsky 1989; Crane 1997, Crane 1999; Douglass et al.. 1988; Iqbal 1998; Keigher and Greenblatt 1992; Kramer and Barker 1996; Kutza and Keigher 1991; Purdon 1991; Rich, Boucher, and Rich 1995; Wilson 1995). In the United Kingdom and the United States, some older homeless people live on the streets while some stay in hostels and night shelters (in the U.K.) or public shelters (in the U.S.), while in Australia, they concentrate in large hostels and night shelters (Purdon 1991). They exhibit high rates of isolation, estranged family relationships, pessimism, and physical and mental illnesses (the latter particularly among women). Although drug abuse is rare among the group, heavy drinking is common among men. Some older rough sleepers claim no Social Security benefits through ignorance of the system, have no income, and survive with food from litter bins or soup kitchens (Cohen and Crane 1996; National Coalition for the Homeless 1997). Some have been homeless for more than 20 years and have become "entrenched" in the lifestyle, whereas others became homeless for the first time in old age (Grigsby, Baumann, Gregorich, and Roberts-Gray 1990). Commonly reported factors preceding homelessness include widowhood, marital breakdown, retirement or redundancy, discharge from the armed forces, and the increased severity of a mental illness (Crane 1999).
Older homeless people tend to be unassertive and undemanding of services, and their needs are met inadequately by both mainstream elderly services and generic services for homeless people. The former are often unable to respond to the distinct problems of older homeless people (Doolin 1986; Purdon 1991) and rarely seek out people who are reluctant or incompetent to ask for help (Crane and Warnes 2000). Most day centers and hostels for homeless people cater to all ages, but many older street people will not use them because they dislike the noise and overcrowding, and they fear violence and intimidation by young users who tend to dominate and are demanding (Coalition for the Homeless 1984; Cohen and Sokolovsky 1989; Crane and Warnes 1997b). Furthermore, generic outreach and resettlement workers who work with homeless people often do not have the time and resources to engage with older entrenched rough sleepers, who are extremely hard to find and more evasive of services than younger homeless people (Randall and Brown 1995; Sheridan, Gowan, & Halpin, 1993).
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Policies and Services for Homeless People |
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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Since the mid-1980s, it has been acknowledged that many homeless people have health, social, and behavior problems, and that the way forward is not just to provide basic shelter and food but also to provide specialist and supportive services that encourage rehabilitation and a move toward independent living. In Australia, the Supported Accommodation Assistance Program was introduced in all states and territories in 1985. This provides joint Commonwealth and State or Territory funding to nongovernmental organizations providing services to homeless people (Purdon 1991). In the United States, the 1987 Stewart B. McKinney Homeless Assistance Act was the first comprehensive legislation pertaining to homelessness (Daly 1996). An Interagency Council on the Homeless was established to coordinate the activities of federal agencies responsible for housing-assistance programs and grants. This has encouraged the development of small transitional and specialized shelters that offer care and support to homeless people and has funded health care, job training, and counseling. In addition to federal aid, state and local governments fund private and voluntary groups to provide services, and local governments also operate public shelters.
In the United Kingdom, in 1990, the Conservative government initiated the Rough Sleepers Initiative (RSI), which over three 3-year phases has allocated more than £255 million for temporary and permanent accommodation for single homeless people, and for outreach and resettlement workers (Department of the Environment et al.. 1995). In addition, there are funding programs specifically to help mentally ill homeless people. Following the election of the Labour government in 1997, the RSI was replaced in April 1999 by the Homelessness Action Programme, which promises a greater emphasis on service development, prevention, and resettlement (Social Exclusion Unit 1998). More hostel beds, "contact and assessment teams" working on the streets and, in London, 24-hour access refuges are to be provided and will herald more coercive actions to stop street living (Rough Sleepers Unit 1999).
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Services Dedicated to Older Homeless People |
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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). These services have demonstrated that older homeless people can be helped by intensive work and specialist facilities, and can be rehoused in conventional accommodation. As examples, in London, Lowestoft (England), Seattle, and Melbourne (Australia), older men who had been resident for years in temporary hostels and shelters have been rehoused in supported housing, and have become more self-confident and sociable. Some drink less, eat better, and take better care of their personal appearance and rooms (Crane and Warnes 1997a; Elias and Inui 1993; Hallebone 1997).
Services specifically for older homeless people, however, are not widespread for three reasons (Cohen 1999). First, as mentioned, there is little awareness of the circumstances and unmet needs of older homeless people. Second, despite the recent elaboration of policies and services for homeless people, the age group is not a high priority for policy makers—young homeless people are—and the services dedicated to older people have generally developed from initiatives by nongovernmental organizations. Some are long established in the sector, others have been founded specifically for the purpose, as with Boston's Committee to End Elder Homelessness in 1991, Peter's Place in New York City (a 24-hour drop-in center), and small rehabilitation houses that help their residents build (or rebuild) living skills and prepare for permanent housing (e.g., Program to Resettle Elderly People (PREP) in Grangetown, Cardiff, Wales; the Zambesi Project in Birmingham, England; and The Dwelling Place in Washington, DC). Third, there have been few formal evaluations or published reports of the experimental schemes (Crane and Warnes 1997a). As a result, the outcomes of different types of interventions are unknown, and good practice is rarely disseminated. One exception is Project Rescue, a day center near the Bowery in New York City for homeless people aged 60 years and older. A 30-month evaluation of the project identified the client characteristics that predicted successful outcomes (Cohen, Onserund, & Monaco, 1992, 1993).
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The Lancefield Street Center |
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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). This led to a proposal for an experimental center that would provide multiple services from street outreach to resettlement for people aged 50 years or older. It was modeled on day centers and outreach work for older homeless people in New York City and Boston (Cohen and Sokolovsky 1989; Doolin 1986). The inclusion of a residential hostel was, however, unprecedented. Substantial financial support was provided by a charitable trust, and a voluntary housing organization, St. Mungo's, came forward to manage the Center; however, the opening was delayed through several refusals of permission by building lessees and for planning (zoning) reasons. The Lancefield Street Center opened in January 1997 and closed in December 1998 when funding and the building lease expired. Its services comprised two street outreach workers; an open-access, 24-hour drop-in center; a 33-bed hostel providing temporary accommodation; access to health care and alcohol abuse programs; and a resettlement program. Its overall aim was to provide services that would enable progression from street living to resettlement in long-term accommodation (Fig. 1). The objectives and work of the four principal services are described in turn.
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The outreach team referred 239 clients to Lancefield Street and 62 to other hostels. Some were persuaded to take this step only after intensive work and diverse help on the streets for many months. The clients were given food, clothing and blankets, taken for medical treatment, and assisted with claims for welfare benefits. When a client showed a willingness to accept services, it was found to be important to respond immediately, which the continuously open drop-in center made possible. Those who had been homeless for years were most resistant to services, and women who were sleeping rough were the most difficult to help: many had severe mental health problems and, compared with the men, they were less willing to talk, more suspicious, and more reluctant to go to the Center.
The Drop-In Center
The drop-in center comprised two sitting rooms, a kitchen, and a bathroom. Users had access to the hostel resident's dining room and laundry, and staff members were available at all hours. The facility was used by 141 men and 13 women, and stays ranged from 2 hours to 87 days. Twenty-five clients used it on more than one occasion. It functioned as a refuge, a "habitat," and a "transit lounge" for those who were distrustful and reluctant to book into the hostel, too unsettled or disturbed to stay in the hostel, or waiting for a vacancy in the hostel, a detoxification unit, or elsewhere. It was an assessment center, where information was collected about the users' circumstances and needs, help and support were organized, and referrals were made to medical, psychiatric, alcohol, and resettlement services. Beyond providing for immediate needs, the facility provided a stepping-stone from the streets. It enabled trust to be built in a safe environment for many people who had previously refused services, and it allowed the most wary of older rough sleepers to be habituated gradually to conventional shelter.
Only a minority of the users immediately returned to the streets: 59 first-time users (40%) moved into the hostel, and 30% were referred to other services. Those who had been homeless for less than a year were the least likely to return immediately to the streets, but even among the 55 users who had been homeless for more than 10 years, 62% moved to temporary accommodation, demonstrating that older people with long histories of homelessness can be persuaded to accept help.
The Residential Hostel
The hostel had 33 beds and was generally full; only 6% of available bed-nights were not occupied. One hundred fifty-seven men and 14 women were admitted on 205 occasions. The duration of the 205 residence episodes varied considerably: 39% were less than 30 days, whereas 32% were for more than 3 months and 11% exceeded 9 months. The average duration of a residence episode was 101 days and the median was 47 days. Of the 171 residents, 49% were aged 60 years or older, 20% had been homeless for less than 3 months, and 42% had been homeless for more than 10 years. On admission, 55% had physical health problems, 39% had mental health problems, and 58% were heavy drinkers. Some had severe physical illnesses, with cases of carcinomas, tuberculosis, liver and renal failure, heart problems, and neurological diseases. Many had not, however, sought treatment while sleeping on the streets. The residents received individualized help from the hostel staff and from specialist workers. Thirty percent received help claiming welfare benefit entitlements, 40% received help with personal care and budgeting, 42% were referred for medical care, and 29% (50) were admitted to a hospital on 107 occasions. Sixty percent of those with mental health problems were referred to psychiatric services, and 36% of those with alcohol problems were seen by specialist workers or admitted to detoxification units.
Resettlement in Long-Term Accommodation
A resettlement worker assessed the housing needs of the residents, found appropriate vacancies, in many cases negotiated with statutory social and mental health services for special funding, and arranged the move and follow-up support. Many residents were difficult to resettle. Twenty-six heavy drinkers refused to cooperate with programs to reduce their alcohol intake, had high personal-care needs when drinking, and were unsuited for independent accommodation. Twelve users feared being rehoused and returned to the streets when housing was discussed or accommodation became available. Twenty percent of the 205 hostel admissions ended with the residents returning to the streets. If unknown destinations are added to this category, the total reaches 44% (Table 1 ). A lower percentage of the destinations following the last episode, however, were returns to the streets (37%). Of the 58 residents who moved to long-term housing, 10 went to conventional independent tenancies, 24 to shared houses for ex-homeless people with nonresidential daily support workers, 17 to residential group homes that are staffed 24-hours/day and provide high care support, and 7 to special accommodation for mentally ill people or heavy drinkers (Table 1 ). Over the life of the project, a rising proportion of the residents were rehoused and correspondingly, the proportion who left of their own accord or returned to the streets decreased.
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). Overall, however, nearly two thirds of the clients contacted on the streets were helped to enter temporary accommodation, three quarters of those who entered the drop-in center moved into hostel accommodation, and one third of the hostel residents were resettled in long-term accommodation. Positive outcomes were therefore predominant but far from universal. The final section of this article examines the factors associated with two selected positive outcomes.
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The Outcomes of Hostel Residence |
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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). Three routine operational data files were established about the outreach workers' contacts, the users of the drop-in center, and the hostel residents. In-depth interviews with 88 residents collected information about social and family relationships, accommodation histories, and experiences of homelessness, physical and mental health problems, drinking habits, and morale. A semi-structured questionnaire recorded the residents' progress every 4 months, the services they received, and the outcomes of referrals, interventions, and medical treatment. One researcher spent at least 2 days every week at the Center, to upgrade the management registers, collect information from the staff, build relationships with the residents, and conduct the interviews. The residents who were rehoused have been included in a longitudinal study (1997–2001) of resettlement for older homeless people. This analysis concentrates on the associations between the onward destinations of the residents after the final episode of residence and both selected personal characteristics and aspects of their hostel residence. Two outcomes have been examined: whether the resident on departure from the Center (a) returned to street living and (b) was resettled in long-term accommodation or had been accepted into a resettlement program. Long-term accommodation was defined as conventional, supported, or high-care housing, and did not include temporary hostels, hospitals, or detoxification units. The second outcome allows for the special arrangements on the closure of Lancefield Street, whereby some residents who were awaiting a tenancy or otherwise accepted for resettlement were transferred temporarily to hostels. Mental health problems were attributed when a person reported current or recent psychiatric treatment or displayed clear signs of dementia or a psychosis (most often pathological delusions). An alcohol problem was recorded when the client showed recurrent heavy drinking or alcohol addiction.
As both outcome or dependent variables are binary, logistic regression was selected as the method of analysis (and the SPSS software was used; Norusis 1990, page B-39). The distributions of and associations among the input variables have, however, been examined for both interval and categorical forms. Models have been calibrated for the full sample of 171 residents, for the 88 who were younger than 60 years of age, and for the 83 who were older. There were just 14 women informants and disaggregation by sex has not been analytically productive. The reference case for the full sample and the older age-group models was specified as a resident who stayed for no more than 25 days, who had been homeless for more than 10 years, was aged 70 years or older, and had neither an alcohol nor a mental health problem. Age does not enter the model for those in their fifties.
Hypothetical models of the two outcomes were developed inductively from the descriptive findings and our observations of both the process of resettlement and the reactions of the residents. The most apparent influence was exposure to the support and help that the center provided. Many of the residents who stayed too short a time to enter resettlement planning returned to the streets, and the few short-stayers who entered long-term housing went to live with a relative. However, of the 10% of residents who stayed the longest (average 430 days), none returned to the streets. The relationship between the duration of residence and the probability of not returning to the streets was nonlinear: the probability increased steeply from 0 for a 1-day stay to 0.95 for a stay of 90 days (Fig. 2). Stays longer than 90 days first reduced the probability, partly because this group had a high prevalence of severe behavioral problems and care needs, but durations of more than 250 days reestablished a positive relationship with the positive outcome. Duration of residence (DURRES) was categorized into its four quartiles (see Table 3 ). There was a similar nonlinear relationship between the duration of the episode and the probability of being resettled in long-term accommodation.
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To check for covariance, the five hypothesized independent variables were cross-correlated. The distributions of the three available interval measures (DURHML, DURRES, AGE) were brought to acceptable approximations of normality using logarithmic transformations. For the entire sample, two bivariate correlations with DURHML were significant at p < .05: ALCPRO gave r = +.20, and DURRES gave r = -.17, so in neither case was more than 4% of the variance explained. Nonlinear associations were examined by calculating the chi-squared statistic for all bivariate cross-tabulations. Only the association between ALCPRO and DURRES (four categories) produced a significant result (
2 = 11.7, p = .008), because there was an exceptionally low prevalence of alcohol problems (34%) among those who had been homeless between 1 month and 2 years when compared with all others (64%).
Similar tests were carried out for the young and old age groups. For those aged in their fifties on admission, the linear interval correlation between DURRES and MENTHE (r = +.30, p = .007) was significant, and that between DURRES and ALCPRO (r = +.23, p = .04) was marginally significant. The categorical cross-tabulations produced no significant chi-squared statistics at p = <.05. For the older age group, there was a significant linear interval association between DURHML and DURRES (r = -.25, p = .03), and there was only one marginally significant bivari-ate categorical association, between DURHML and ALCPRO (2 = 7.88, p = .049). The covariation that is present is therefore modest for both age groups and the full sample. The full theoretical model—that the two outcomes are both influenced by duration of residence, duration of homelessness, age on admission, and the presence of alcohol and mental health problems—was therefore retained.
In exploring the relationships, both backward and forward stepwise selection using the likelihood-ratio test have been used, the variable inclusion criterion being an improvement to the model at p < .05, and the exclusion criterion being p < .1. It was quickly established that AGE, DURHML, and MENTHE had no significant influence on any model. As they reduced the sample size (through missing data), they have been excluded from the reported models. Similarly in the models that did not select ALCPRO, that variable was excluded from the final runs.
Results
The three age-group models of whether the residents returned to the streets have a similar structure, with DURRES being the only significant variable (Table 3 ). Moreover, the structure of influence of the individual categories is shared. The base case models predict a very low probability of the successful outcome (row e), while the categories for longer stays are associated with a progressively higher probability of not returning to the streets (rows j, n, and r). The highest category is for residents who remained more than 144 days: all three age-group models predict a probability of not returning to the streets of at least 90%, compared with 12–27% for the base case. In addition, all three models increase the share of correctly predicted cases (over a single outcome prediction) by at least 25% (row cc).
The second set of models examines the factors influencing "resettled or not." The relative frequency of the positive outcome was significantly lower in the younger than the older age group (2 = 6.25, df = 1, p < .02), and the logistic regressions suggest some contrasts in the structure of influences. DURRES is again included in all models, and its successively higher categories (of longer stays) produce similarly progressive increases in the probability of a positive outcome. No other variable enters the model for the older age group. In contrast, the models for the younger and all-age groups also select ALCPRO (the presence of an alcohol problem), which reduces the probability of being resettled. The partial correlation for ALCPRO is low (row w) and the influence is only marginally significant (row u). The younger age group model does nonetheless produce a significant improvement over a single outcome prediction (row z) if only a modest increase in the correct prediction of individual cases (row cc). Despite the weak associations of the individual terms, the model confirms the very strong influence of variations in the duration of stay. It predicts that residents who stayed in the hostel just 0–25 days had a 0.0 probability of being resettled, whereas for residents without an alcohol problem who remained more than 144 days the probability rose to 0.70. For the longest stayers with an alcohol problem, the probability of being resettled was raised to 0.40.
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Discussion |
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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The Lancefield Street Center provided a "complete pathway" from the streets to long-term housing for many older rough sleepers. The outreach team initiated the majority of the users' contacts with the project and had an important role in engaging and building relationships with those who were isolated and resistant to services. The effectiveness of persistent and intensive street outreach work with "hard-to-reach" street dwellers has been noted in other U.S. and British reports (Morse et al.. 1996; Craig 1995; Sheridan et al.. 1993). The drop-in center served as a stepping-stone from the streets to the hostel for the distrustful and anxious, and is comparable to the "community living room" and the "street center" described in U.S. studies (Pollio 1990; Segal and Baumohl 1985). The drop-in center and the hostel helped older street people to settle, linked them to services, and encouraged them to consider more conventional accommodation. The resettlement component was crucial for completing the pathway and moving the residents to long-term housing, and in releasing the hostel beds for others. The model could be applied to other entrenched street people who are severely incapacitated by mental health or substance abuse problems.
Even in the short life of this scheme, several lessons have been learned about effective ways to develop services for older homeless people. Many older rough sleepers who do not use generic homeless services will respond to the intensive encouragement and support provided by dedicated services, can be persuaded to take up residence in temporary accommodation, and will then accept more permanent housing. The Lancefield Street Center reduced the number of older people living on the streets of London. Its interventions produced long-term accommodation prospects for around one half of its residents, and the early evidence from the longitudinal study of resettlement suggests that approximately one third will adapt to conventional accommodation. Many older people who were demoralized and resigned to homelessness are already developing new roles and activities.
In describing the limits and lessons of the Lancefield Street Center experience, it becomes evident, first, that it is important to identify and help people soon after they become homeless; second, that older homeless people must be encouraged to remain in contact with services and support staff long enough to benefit from help; and third, that more needs to be understood about effective ways of helping those with an alcohol problem. Heavy drinking reduced the client's ability to be rehoused and to live independently, increased the chances of returning to the streets, compounded physical health problems, and was associated with depression and pessimism. More needs to be known about the types of counseling services and other interventions that effectively help people to reduce heavy drinking and to rebuild their lives. Further experimental services should be tried, and the experience of each project should be rapidly disseminated. It is clear from the Lancefield Street Center initiatives that there are many older people living on the streets and in temporary hostels who will respond to empathetic individualized help and who will return to conventional accommodation and daily routines.
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Acknowledgments |
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Received for publication July 13, 1999. Accepted for publication February 21, 2000.
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TOPAbstractThe Problems and Needs...Policies and Services for...Services Dedicated to Older...The Lancefield Street CenterThe Outcomes of Hostel...DiscussionReferences |
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This article has been cited by other articles:
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  M. Crane and A. M Warnes Primary health care services for single homeless people: defects and opportunities Fam. Pract., June 1, 2001; 18(3): 272 - 276. [Abstract] [Full Text] [PDF]
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