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Reasons Why Folks Sleep Outside

Sally Erickson and Jaimie Page

To Dance With Grace: Outreach & Engagement To Persons On The Street
Sally Erickson, M.S.W.
Jaimie Page, M.S.W., L.S.W.

Outreach and engagement strategies are critical in helping homeless persons transition from the streets into housing and services. A literature review was conducted and commonalities across populations were found (although the preponderance of literature describes homeless persons with mental illnesses). Definitions, exemplary practice models, values/principles, worker stances, measurable outcomes, and multi-level factors relating to outreach and engagement are presented as well as issues related to research and funding.

Lessons for Practitioners, Policy Makers, and Researchers

Outreach work is based on a foundation of strong values, principles and unique worker stances
Engagement is the key in Outreach
The homeless persons outreach is designed for are those who unserved or underserved by existing agencies and who aren’t able or willing to seek services from those agencies
The goals of outreach are to develop trust, care for immediate needs, provide linkages to services and resources, and to help people get connected to mainstream services and ultimately into the community through a series of phased strategies
Effective outreach has been demonstrated, with positive outcomes
Peer based outreach and the use of the expertise of homeless and formerly homeless persons and consumers are valued and should be actively sought out
Discrimination and marginalization are part of the experience of both outreach clients and workers; as a result, advocacy must take place at all levels
Outreach services cannot exist in isolation from larger systems: both homeless systems and mainstream systems at community, state, and federal levels
Outreach services must be included, required, valued, and funded as part of a national and local continuum of care
More research, including controlled and longitudinal studies, are needed particularly in answering the question of what factors promote success in helping people access mainstream services and resources across homeless outreach populations
The process of outreach and engagement is an art, best described as a dance. Outreach workers take one step toward a potential client, not knowing what their response will be—will the client join in or walk away? Do they like to lead or follow? Every outreach worker has a different style and is better at some steps than others. To dance with grace, when the stakes are high, is the challenge for all of us.

In the U.S., we now have the benefit of more than ten years of McKinney funding which has made possible scores of outreach programs across the country. Rural and urban, small and large, comprehensive or finite, they reach out to people who are homeless and challenged by poverty, violence, marginalization, poor health, mental illness, substance abuse, and other issues.

This paper will provide definitions; exemplary practice models, including worker stances, values/principles, outreach functions and services, outreach across populations; measurable outcomes; and an extensive bibliography for further inquiry. The preponderance of available literature was published in the late 1980s and early 1990s, and focuses on mental health-related outreach programs. The few outreach-related articles published in recent years perhaps reflect the greater use, acceptance, and integration of existing outreach programs as part of a community’s effort to provide a “continuum of care” to persons in need. This paper will present both a review of the literature and experiential information relating to best practices.

Priority Home! (1994) describes the federal plan to break the cycle of homelessness by “public and private mental health, medical, and substance abuse service-providers to initiate street outreach efforts, the utilization of safe havens … and implementation of a continuum of care…” This federal validation of outreach as an accepted and expected part of a community solution to homelessness, which includes access to housing and services, recognizes the unique efforts of outreach workers across the country.

Outreach is the initial and most critical step in connecting, or reconnecting a homeless individual to needed health, mental health, recovery, social welfare, and housing services. Outreach is primarily directed toward finding homeless people who might not use services due to lack of awareness or active avoidance (ICH, 1991; McMurray-Avila, 1997), and who would otherwise be ignored or underserved (Morse, 1987). Outreach is viewed as a process rather than an outcome, with a focus on establishing rapport and a goal of eventually engaging people in the services they need and will accept (ICH, 1991; McMurray-Avila, 1997). Outreach is first and foremost a process of relationship-building (Rosnow, 1988) and that is where the dance begins.

Engagement is a crucial process for successful outreach. It is described as the process by which a trusting relationship between worker and client is established. This provides a context for assessing needs, defining service goals and agreeing on a plan for delivering these services (Barrow, 1988, 1991; ICH, 1991; Winarski, 1994). Some clients require slower and more cautious service approaches (Morse, 1987). The engagement period can be lengthy-and the time from initial contact to engagement can range from a few hours to two years (ICH, 1991) or longer. Effective workers can “establish a personal connection that provides a spark for the journey back to a vital and dignified life” (Winarski, 1998).

Assumptions Of Exemplary Programs
Based on a review of the literature and best practices found in the field, the following are important elements to address in a good outreach program: characteristics of the population served, values and principles, worker stances/characteristics, and goals of outreach.

Programs cannot assume is that all communities have the same percentages of “types” of homeless people. There is a range in the population that may differ from one region to the next. Rather than basing interventions on formulaic assumptions such as “1/3 mentally ill, 1/3 veterans, 1/4 families,” each community needs to assess the characteristics of it’s homeless persons, identify service gaps, and develop effective responses. For example, in one city 80 percent of the homeless were single men, while in another, 65 percent were families with children (U.S. News & World Report, 1988).

Characteristics Of Homeless Persons Needing Outreach

Outreach programs attempt to engage individuals who are unserved or underserved by existing agencies (Axelroad, 1987). This distinction is significant because the outreach model was developed to meet the large service gap found among this unique population. An outreach model is unnecessary and even counter-productive with other populations.

Outreach programs serve persons who may have psychiatric disorders and/or substance abuse issues. They may be highly vulnerable and considered “difficult to serve” (Rog, D.J., 1988). They usually cannot negotiate the requirements of or trust traditional service-providers. These persons may have poor health, lack insurance, and are unable to make or keep medical appointments and follow through with complex medical regimes. Homeless youth may be those who are estranged from family and fearful of adult service-providers. Homeless youth are perhaps the most vulnerable group of youths, and are in need of creative and early interventions, in order to prevent an acclimation to street life which includes prostitution, substance abuse, and crime. Further, homeless teems with children are viewed as perhaps the most vulnerable of homeless families (Bronstein, 1996).

Two factors commonly associated with homelessness among women include pregnancy and the recent birth of a baby. Homeless pregnant women experience a range of problems including poverty, isolation, substance abuse, and histories or past and present victimization. A lack of prenatal care and poor nutrition may also exacerbate health problems (Weinreb, et al., 1995).

Other groups include the elderly, women escaping domestic violence, families, and marginalized persons such as those who are transgendered and those in the sex industry.

Many of the people outreach programs attempt to serve are isolated, have minimal resources, minimal access to social services (Sullivan-Mintz, 1995; ICH, 1991), have had negative experiences with service-providers (McMurray-Avila, 1997), and have been victims of violence (Goodman, et al., 1995; Weinreb, et al., 1995). Workers give priority to those who are most at-risk who are least likely to seek out and successfully access available services, for whatever reason: fear, mental status, lack of insight and motivation, or low self-esteem. Rog (1988) describes the need to reduce barriers to service-utilization and facilitate the engagement process. Workers may also encounter persons who are able to access services and can help by providing one-time information and direction, but the focus is on the former group.

Values & Principles Of Outreach
Successful outreach programs must be based on a core set of values and principles which drive interventions. Values and principles also serve to set the stage for developing realistic goals in an arena of limited resources and potentially slow progress.

A person orientation: Exemplary programs possess a philosophy which aims to restore the dignity of homeless persons, dealing with clients as people (Axelroad, 1987; Wobido, 1990).
Recognizing clients’ strengths, uniqueness, and survival skills.
Empowerment & self-determination: (Sullivan-Mintz, 1995) Workers can facilitate this by presenting options and potential consequences, rather than solutions (Rosnow, 1988), by listening to homeless persons rather than “doing” for them, and by ensuring a balance of power between homeless individuals and outreach workers (Rosnow, 1988).
Respect for the recovery process (Winarski, 1994): Behavior change is on a continuum. Small successes are recognized. Any move toward safer/healthier activities is viewed as a success. Clients need to recognize for themselves how change may be beneficial, in relation to their own goals.
Client-driven goals (Winarski, 1994): Services and strategies are tailored to meet the individuals’ unique needs and characteristics (Morse, 1987). Workers start with clients’ perceived needs and go from there.
Respect (Cohen and Marcos, 1992): Workers are respectful of people, including their territory and culture. Outreach workers view themselves as a guest and make sure they are invited, welcome, or at least tolerated. Workers must take care not to interrupt the lifestyle of the people they are trying to help. Lopez (1996) makes the point that clients don’t lose the right to be left alone in the privacy of their home even when that client calls the streets home. Clients are viewed as the experts in their life and on the streets. The worker takes the role of consultant into that lifestyle.
Hope: Workers instill a sense of hope for clients while helping them maintain positive, realistic expectations. Unrealistic expectations may bring on clients’ cycles of frustration, despair, and hopelessness, as well as anger at the outreach worker. The worker restores hope in clients who have faced years of disappointment as well as reframes raised expectations. The worker needs to communicate to the client that changes may take considerable time, effort, and patience (Morse, 1991).
Kindness: People are always treated with warmth, empathy and positive regard, regardless of their behavior or presentation.
Advocacy: Workers advocate for social justice on many levels.
Outreach Worker Stances/Characteristics
There are common worker stances/characteristics found among successful outreach workers and programs. These characteristics are critical because successful engagement will largely be determined by the relationship between clients and workers. Effective worker stances/characteristics include:

Good judgment, intuition and street sense: this includes safety for themselves and the client-being observant and vigilant, as well as using good common sense. Strategies include going out with a partner, avoiding closed, remote or dangerous areas, developing a relationship with local police (Winarski, 1998), carrying a cellular phone, dressing appropriately, and assessing situations before acting.
Non-judgmental attitude (ICH, 1991): Regardless of the worker’s personal beliefs, no behavior on the part of the client is morally judged.
Team player: Workers must know when to ask for help, from getting backup on the streets to a second opinion in clinical assessments. Outreach staff must have a strong commitment to the “team” approach to service delivery (Axelroad, 1987; Wobido, 1990).
Flexibility (Rosnow, 1988;ICH, 1991): Outreach workers are flexible in reassessing daily work priorities, in setting work schedules, and in the treatment planning process (Morse, 1987), and content.
Realistic expectations: Workers have an “expectation of non-results.” They understand that they will not be able to “cure” or “save” clients (Axelroad, 1987; ICH, 1991), and at the same time continue to persevere.
Commitment: Outreach workers are both consistent and persistent in their dealings with clients (Axelroad, 1987; Wobido, 1990). They do what they say they are going to do and only make promises they can keep (Sullivan-Mintz, 1995). They are in it “for the long haul” and continue to persevere.
Less is more. At the outset of intervention, there is less application of intensive and costly treatment, less professional distancing, less rigidity, less intrusiveness, and less directiveness (Rosnow, 1988). Services offered are purely voluntary (Cohen, 1989).
Altruism: Staff find rewards in doing outreach work, such as a spiritual commitment to helping others, furthering an academic interest, or simply enjoying the process of working with individuals (Axelroad, 1987).
Sense of humor: the ability to use humor at appropriate times, as well as maintaining as sense of humor during difficult times is essential.
Creativity & resourcefulness are strengths that outreach workers tap into daily.
Cultural competency: Workers demonstrate competence across ethnicity, gender, transgender, lifestyle, and age spectrums.
Resilience: Workers are resilient and patient in a work environment marked by high turnover, difficulty tracking clients (McQuistion, et al., 1996), high stress, lack of resources, and lack of immediate improvement in the clients they serve. Effective workers are able to continue working despite the difficulties endured by their clients, without personalizing them.
Outreach programs vary in relation to considering credentials, ethnicity, or gender when hiring outreach workers. People with a variety of backgrounds may function as mental health outreach workers: physicians, social workers, nurses, nurse-practitioners, and para-professionals. Some programs employ formerly homeless persons with mental illnesses (Axelroad, 1987; Morse, 1987). A survey of ACCESS programs reported that 75 percent of programs do not require a bachelor’s degree for an outreach worker. More important were characteristics such as a personal commitment to the work, flexibility, and a willingness to adjust schedules to the needs of the clients (Wasmer, 1998).

Some programs state that it is not necessary to have workers of the same ethnicity, cultural background or gender as the clients, nor who have a lot of street experience. They further state that the only essential characteristic is a common language (Axelroad, 1987; Nasper, 1992). However, an outreach team of two males in Milwaukee found that they had served 80-90 percent men and had difficulty establishing trust with homeless women. As a result, they now have mixed gender teams (Rosnow, 1988). Agencies promote an equal opportunity atmosphere, and the staff composition mirrors that of the general population.

Many outreach programs successfully use mental health consumers as outreach workers (Tosh, 1990 and 1993, and Lieberman, et al., 1991) and/or formerly homeless persons (Mullins, 1994). The benefits of such peer models allow for effective outreach, sharing of their personal expertise, fostering of partnerships between consumers and non-consumers, increased self-esteem of the working peers, and the evolution of consumers becoming active in changing services throughout the country. Consumers/peers/formerly homeless persons can contribute significantly in the development of program design, implementation, and evaluation. Their expertise should be actively sought out by outreach programs. To be sure, homeless persons and formerly homeless persons have expertise, skills, and insight that professionals who have never experienced homelessness lack. Programs recognize that peers working in homeless and mental health fields often endure the pressures of maintaining their own housing and overcoming stigma (Tosh, 1993), allow for reasonable accommodations to assist them, and offer training and on-going meetings (Leiberman, et al., 1991).

Goals of Outreach
There are four main goals of outreach found across different areas of outreach client populations. The first is to care for immediate needs (Plescia, 1997), including to ensure safety, provide crisis intervention, refer to immediate medical care, and help clients with immediate clothes, food, and shelter needs. Workers must develop a trusting relationship (Plescia, 1997; Cohen and Marcos, 1992; Sullivan-Mintz, 1995) in order to achieve the additional goals of providing services and resources, whenever and for as long as needed (Winarski, 1998). Lastly, workers aid in connecting clients to mainstream services (Plescia, 1997).

An inherent factor related to these goals is the notion of phasing. Objectives are developed and reached over a period of time with small steps that are directed to a more structured, service-oriented goal. Persons often phase from accepting food from the outreach worker, to developing trust, to discussing a goal that in part can be achieved through services provided in the community and to accepting those services. Case management goals are gradually developed by both the client and worker. Outreach and engagement principles carry over into case management and are viewed as an ongoing process. As trust develops, clients take a more active role in setting and achieving case management goals. Ultimately, the goal is to successfully phase or integrate persons into the community and/or into a social service agency (ies) which would assume the task of promoting community integration. Just as clients are phased into outreach services from the streets, they are phased into the community from outreach.

Outreach Service Structure
There are at least three ways of classifying outreach models found in the literature. One set looks at a linkage model versus a continuous relationship model. A second set looks at a mobile versus fixed model. A third set describes models based on a service continuum.

Linkage vs. Continuous Relationship Model

Some outreach programs serve as linkages, referring clients to mainstream mental health or other service-providers. Examples of “find and link” programs are New York’s Project HELP, which conducts in-vivo assessments and delivers people to the psychiatric hospital by voluntary and involuntary means, and Chicago’s Mobile Assessment Unit (MAU), that visits shelters and streets to identify mentally ill persons and link them to resources (Wasmer, 1998). Other examples may include linking temporarily displaced families with housing.

Linkage-only programs that do not provide follow-up tracking have been determined to be ineffective for some disabled populations. A 1986-87 study of 13 federally funded homeless mental health demonstration programs reported that most outreach programs were running ineffective models. Many spent the majority of their time in screening and identifying individuals and providing verbal referrals, but little follow-up assistance. One project contacted 430 eligible persons, yet only 22 received follow-up mental health treatment. Five found housing and three received entitlements (Hopper, et al., 1990 in Morse, 1996).

Providing linkage-only services to certain homeless populations can lead to barriers and service gaps, resulting in lost clients. Morse (1991, 1996) suggests strategies to increase the effectiveness of this model: incorporate the expectation of an eventual service-provider transition early in the engagement and service-planning with a client; remain involved and actively involve the client in the referral process, including scheduling appointments, arranging transportation, and providing emotional support; work with the linkage site staff, informing them about client needs and characteristics; provide follow-up support as needed to both client and new staff; and provide advocacy on behalf of the client if needed.

In a continuous relationship model, workers perform outreach and continue on as the person’s case manager. Outreach has been shown to be a necessary component of ongoing case management for mentally ill clients. Axelroad and Toff (1987), point out the difficulty in distinguishing outreach from case management for homeless mentally ill persons for two reasons. First, the fragility of the population requires trust and continuity of care when helping clients move from an outreach phase to a treatment phase. Second, outreach workers must often provide case management services because of the frequent shortage of appropriate and relevant case management services for which to refer clients.

The drawbacks to the continuous relationship model are small recommended caseloads, 10:1, which may be unrealistic for many agencies, and little capacity to outreach with new clients (Morse, 1991, 1996). However, the approach has been shown to be effective at maintaining contact with clients and housing retention (Morse, 1996). In addition, outreach workers may prefer the excitement, lack of structure, and immediacy of outreach. For this and other reasons related to individual personality traits, some outreach workers may not be as effective as case managers.

At Safe Haven in Honolulu, outreach workers opted for the continuous relationship model out of necessity when they were unable to transition “graduated” residents to case managers at the community mental health centers. Historically, the engagement strategies used in interaction between clients and outreach workers have been substantially different from strategies used at traditional service settings, leaving clients with little incentive to transition to a less user-friendly service-provider. Outreach roles expanded to encompass case management and advocacy, and they remained connected with clients through follow-up. Perhaps as a result, a majority of Safe Haven clients have successfully transitioned into the community. In Safe Haven’s first 28 months, 43 residents transitioned from the program—63 percent into permanent independent housing, with 98 percent of these retaining their housing.

Mobile vs. Fixed

Outreach may be mobile or fixed depending on the needs of the target population (Sullivan-Mintz, 1995). Outreach may take place on the streets, as well as in shelters, drop-in centers, emergency rooms, hospitals, and jails (Axelroad, 1987; Morse, 1987). The mobile model requires that the projects be “equipment heavy,” including agency vehicles/vans, employee cars, and communication systems such as pagers, cellular phones, and walkie-talkies (Wasmer, 1998).

Fixed-site outreach programs such as drop-in centers or day programs for the mentally ill, within high-density homeless areas, can be more easily accessed by greater numbers of clients, increase staff efficiency, and can provide additional incentive services. Many outreach programs have both a mobile and fixed-site component (Morse, 1987). In a survey of eight ACCESS programs, 77 percent of clients were engaged by mobile methods and the balance at drop-in centers. (Wasmer, 1998)

For certain clients with primary substance abuse issues, mobile outreach is more successful for several reasons. There is less stigma and community opposition when outreach workers meet clients individually on the streets rather than having clients come to a centralized location. Another reason is that clients who are high or intoxicated are often asked to leave fixed service sites.

Outreach Continuum
Wasmer (1998) describes a link/serve continuum, with outreach programs that “find and link” or “find and serve.” The latter include case management programs, assertive community treatment and intensive case management programs, drop-in centers, shelter-based programs, and low demand residences/safe havens. Of eight ACCESS outreach programs Wasmer surveyed, all were the “find and serve” type.

The Team Approach
Different types of team approaches are described in the literature, depending on the mission of the team. They may focus on emergency psychiatric intervention, case management, health care, HIV education/prevention, harm reduction for sex industry workers, substance users, and others.

With mentally ill persons, using a team approach after engagement has been established assures that a client will learn to develop trusting relationships with several staff people. It also increases the likelihood of being able to attain assistance when necessary. Teams can include or have access to social workers, nurses, nurse-practitioners, substance abuse staff, medical and psychiatric consultants, and other outreach specialists. The team approach can also aid in combating burn-out and expanding caseloads (Axelroad & Toff, 1987) and the inherent sense of isolation individual outreach workers can feel. A study of five New York outreach programs showed that 98 percent of homeless mentally ill clients had a significant relationship with more than one staff member, indicating that involvement with the programs did not consist only of the client’s relationship with a single worker (Barrow, 1988).

One survey of eight ACCESS-funded outreach programs reported that all sites used a team approach, with majority of first contacts made by two mental health professionals, one taking the lead and one observing (Wasmer, 1998).

Exemplary Outreach Functions/Services
Based on a review of the literature (Winarski, 1994, 1998; ICH 1991; Morse, 1996) and review of best practices in the field, several outreach functions/services are common among exemplary outreach programs.

Determine the Target Population
Outreach programs cannot serve all potential clients. Exemplary programs have clearly defined program goals and objectives. Some programs target a subset of the population, such as persons with mental illnesses, and others limit outreach to a particular geographic or “catchment” area (ICH, 1991).

If geographic limits or catchment areas are a defining factor in determining the target population, then the size of the area allows for repetitive contact. Knowing fewer clients better is the goal. Workers have the flexibility to leave this zone and follow their potential clients elsewhere (McQuistion, 1996). If a client is determined to be out of the mission of the outreach program, provisions can be made for referring non-target clients to the appropriate programs. (ICH, 1991).

Locate Street Dwellers
Once workers identify the target population, the next task is to locate them. Individuals can be found under bridges and freeway overpasses, alleys, parks, and vacant lots. In rural areas or on the fringes of urban areas, outreach workers may go to the beaches, riverbanks, foothills, wooded areas or desert. They may be in public facilities such as libraries, airports, and bus stations. They may be in places where people live on the edge of homelessness, such as welfare hotels, cheap motels, and SROs. Some teams have special arrangements with jails, detox/treatment programs or other institutions, to enter and make contact with ongoing clients or potential clients regarding available services on their release (McMurray-Avila, 1997).

Sometimes homeless persons will serve as voluntary scouts for outreach workers, alerting them to homeless persons who appear to be in need of intervention. Volunteer homeless persons can also help outreach workers locate clients who have been missing for some time. Outreach coalitions, comprised of outreach workers from different agencies, can meet periodically and help each other locate missing clients, as well as help each other stay on top of recent trends in geographic concentrations of homeless persons.

Outreach conducted by peers, such as youth, substance users, or sex industry workers, can be effective in locating, engaging, and completing assessments of the clients perceived needs. When going out in teams with non-peer professionals, they are able to introduce professionals to participants on the streets. Youth who serve as peers/mentors for other homeless youth, for example, help convey a sense of understanding of the factors that may have led them to becomes homeless such as abuse and share resource information, teach safety, and help make a bridge between street life and the world of “professional” adults whom they generally don’t initially trust. Hiring program participants encourages increased feelings of self-esteem and empowerment on the part of participants and generates empathetic, effective outreach staff (Mullins, nd). An effective outreach program for at-risk HIV youth in the sex industry in New York provides training to peer youth outreach workers, a support group, an active and real voice in program development, and a stipend for their work. These youth outreach workers have been successful in saving lives and reducing risk associated with their lifestyle and that of their peers in a way that adults could not have.

Engagement is a crucial, on-going, long-term process necessary for successful outreach (Morse, 1991, 1997). In a study of five New York outreach programs, homeless mentally ill clients first contacted by outreach workers were engaged an average of 3.9 months before intensive services began (Barrow, 1988).

Engagement reduces fear, builds trust, and sets the stage for “the real work” to begin (Cohen, 1987). Morse (1991) classifies engagement in terms of four “stages”: 1) setting the stage, 2) initial engagement tactics, 3) ongoing engagement tactics, and 4) proceeding with the outreach/maintaining the relationship.

Setting the stage: Workers become a familiar face and begin to establish credibility in places where homeless persons frequent (Morse, 1991). They use a non-threatening stance/approach (Cohen and Marcos, 1992), and get some kind of permission from the client, either verbal or non-verbal, before approaching. In these early stages, workers gently cease interactions that appear too overwhelming to clients and try again later.

Initial engagement tactics: Workers attempt to engage the potential client in conversation, beginning with non-threatening small talk (Morse, 1991). This allows workers to assess for signs of problems and also the impact of the interaction. Is the client feeling intruded upon (Morse, 1991)? Workers provide incentive items (Cohen, 1989; Cohen and Marcos, 1992) such as food, drinks, condoms, cigarettes, vitamins, toiletries, etc., with real and perceived benefits that promote trust.

Ongoing engagement tactics: Workers begin to “hang out” and “share space” with clients (Morse, 1987). As clients become more comfortable, workers begin to provide or help the client to meet some important needs that can be easily solved or obtained. This might include providing transportation to get clothes, linking the client with medical care, and providing incentive services that are based on clients’ perceived needs (Cohen, 1989). Engagement strategies used in the initial phase continue.

Proceeding with outreach/maintaining the relationship: As trust is established, workers help clients define service goals and activities, which may include the pursuit of housing, income, and medication (Morse, 1991). Staff accompany clients to appointments, help them prepare for upcoming tasks, and assist in the negotiation of service settings.

At Honolulu’s Health Care for the Homeless Project, staff use six simple engagement strategies in their interactions with diverse groups.

Treating people with positive regard, by demonstrating that workers are glad to see them and care about them. Workers remember details of past encounters and discussions. Workers are honest, humble, and share information about themselves when appropriate, to equalize power and respect.
Working with their perceived needs
Providing incentive items and services, as listed above.
Letting clients set the pace whenever possible
Communicating effectively, both verbally and non-verbally. For example, workers get to the client’s level. If the client is sitting on the curb, the worker sits on the curb. Workers gauge the expression of language so that it fits with that of the client’s in terms of vocabulary, speed, eye contact, and culturally relevant responses.
Being creative. For example, an outreach dog is used by one worker. A pet is a great ice-breaker and has been effective in connecting with some paranoid and very isolated mentally ill persons. One woman who would previously never speak to workers, will now talk to the dog (but still not to the worker), providing opportunities for ongoing assessments, and topics for future discussions. Staff use art as an engagement tool, and incorporate client interests, like hobbies, books, and collections, in incentive items and discussions. When possible, outreach workers transfer engagement strategies on the streets to the clinics, where clients can receive further care. For example, a drawing by a client on the streets might be displayed in the clinic where pertinent services are offered. Other effective programs use creativity as an outreach foundation and reach out and engage homeless persons through such non-traditional approaches as the use of theater, the arts, and creative grass-roots community organizing.
Workers need to conduct an assessment of an individual’s comprehensive, holistic needs before providing services and linkages to meet these needs (Morse, 1987). The assessment process is informal and usually takes place over time. Outreach workers, rather than asking direct questions, may make inferences (Cohen and Marcos, 1992) about an individuals’ mental and physical state. As the relationship builds, workers may be able to ask more direct questions as they try to get more history.

The crises faced by many homeless persons are usually related to basic survival, such as lack of food and water, lack of clothing, exposure, poor health, and deteriorated mental status. Outreach workers must initially provide basic triage assessment to help identify and respond to potential life-threatening problems.

When clients are experiencing potentially life-threatening problems such as dangerousness to self or others, serious medical problems, or exposure to extreme cold or heat, outreach workers must be prepared to intervene. Whenever possible, workers should encourage clients to voluntarily accept treatment, and present this treatment within the context of the client’s perceived needs. When the situation is life-threatening, workers should be prepared to initiate involuntary treatment or interventions that will reduce harm. Clinical supervision in this situation is highly recommended so as to not infringe upon clients’ rights and self-determination.

Provide Basic Support
In response to a lack of homeless persons being able to get their basic needs met, workers help them to access food, clothing, shelter (Axelroad, 1987), showers, laundry, and basic medical care. In some cases, homeless persons may not perceive these as basic needs, particularly in the case of those with severe mental illness who have decompensated and/or those with chronic substance use problems. They may perceive other needs as more important. In these cases, workers can educate people about the resources available when they’re ready for them, encourage them to use them when needed, accompany them to the service sites, and suggest what may be a marriage of the worker’s perception of what the homeless person may need, and what the person him/herself feels they need.