The San Marco Project

Transcription

1 The San Marco Project Research conducted through the Masters of Social Work program at the University of Minnesota Duluth Laura Cole, MSW Student Dennis Falk, Ph.D., Research Advisor

2 Introduction A place to call home where one feels safe and secure is a basic human right. Few would argue with this statement, particularly those in the human services field. Homelessness in the United States is on the rise. Those who are homeless represent individuals who have fallen through the cracks of our government s systems. In the current economic recession, individuals continue to struggle with poverty as the unemployment rates rise. Human service agencies are stretched thin, with fewer resources to provide for those in need. The homeless are typically those who are living well below the poverty level. Homelessness has many costs to taxpayers and to the overall health of communities. Homeless people sleeping in alleys and under bridges is inhumane, and an indication of an unfortunate illness afflicting cities as well as smaller towns and communities. Our society often blames the homeless for their predicament, and social welfare policies reflect the United States mentality that people are autonomous and responsible for their own situation. According to research conducted by Podymow (Podymow, Turnbull, Coyle, Yetisi, & Wells, 6), homeless individuals have a higher rate of using crisis services, such as emergency departments, police assistance and detoxification centers. Additionally, homeless individuals have a higher rate of chronic illness, longer hospital stays and increased mortality (Podymow, et al, 6). Larimer et al (9) estimated mortality rates at or more times that of the general population. Mental health, chemical dependency and related problems, including health, financial, social and legal issues, have both direct and indirect costs to individuals and communities.

3 This research study will focus on the San Marco housing project, which is Duluth s solution to some of the problems related to homelessness and chronic alcoholism. By providing homeless individuals with chronic alcoholism housing, it reduces public services that would otherwise be utilized by this population. This study will specifically determine if there is a reduction in detoxification services and an improvement in overall functioning for those residing at the San Marco. Literature Review Homelessness, Chemical Dependency and Mental Health. Some research has indicated that policies regarding the homeless have changed from those that address the problem to those that treat homelessness as the problem. Criminalizing the behaviors of the homeless, such as panhandling, loitering, and violations of open container laws, further marginalizes this population and could lead to increased criminal records for homeless individuals. In many cities, efforts to clean up downtown areas and promote increased development have led to a movement to eradicate the homeless from where they once resided, such as city parks, forcing them to relocate (Miles, ). Many people fear the homeless. According to the findings of Barak (99), the homeless are not any more dangerous to society than the general population, and on the contrary they are more likely to belong to a class of vulnerable people. Characteristics of homeless individuals include those who are displaced, deinstitutionalized, mentally ill, alcoholic or addicted to drugs. Homeless people are often victims of abuse, violence and sexual assault. They are runaway, abused or neglected teens. Many homeless are immigrants, refugees or war veterans. Many are families. Many are children.

4 Those seeking to house the homeless typically work within three phases along a continuum of care: outreach, transitional housing and permanent housing (Tsemberis, Gulcur, & Nakae, ). Outreach programs seek out homeless individuals in an attempt to offer services. Transitional housing seeks to stabilize the individual by providing services and encouraging sobriety, mental health care, medical care and skills to retain housing. It is often required that a person is sober with mental health symptoms under control for housing readiness among traditional continuum of care approaches. Permanent housing may also have rules that are difficult for individuals to live by. Public housing has a specific set of rules and regulations, and if an individual violates these rules, for example by inviting other homeless friends stay with them, they will likely face eviction. Consumers of services often see the program requirements to get treatment for mental health and chemical dependency issues as obstacles to receiving housing. Alcohol use or refusing chemical dependency treatment may disqualify individuals from housing programs. Their use may be the basis for getting terminated from transitional or permanent housing programs. Simply finding a place to live is the first priority for many of those actually experiencing homelessness (Tsemberis, Gulcur, & Nakae, ; Larimer et al, 9). Research has shown that the majority of individuals who experience homelessness have issues with alcoholism, with rates varying from % - 7% (Podymow et al, 6). Additionally, homeless individuals have success rates in chemical dependency treatment that are equal to or less than the general population, primarily due to difficulties adhering to program structure (Orwin, Garrison-Mogren, Jacobs, & Sonnefeld, 999). Journal articles from as early as 98 suggest that homeless shelters have become responsible for meeting the needs of mentally ill homeless persons who are not cared for by health and human service agencies (Bassuk, Rubin, &

5 Lauriat, 98), perhaps due to a lack of services for those who became deinstitutionalized in the 98 s. Of particular concern are those individuals with a dual diagnosis of mental health and chemical dependency issues, an extremely vulnerable population representing an estimated %- % of homeless individuals (Drake, Osher, & Wallach, 99). Those with dual diagnosis in reality suffer from multiple impairments including medical illness, legal problems, lack of independent living skills, a history of trauma and a lack of or antisocial support system. Drake et al, recommend housing this vulnerable population in safe, supportive and structured environments with reduced availability of abused substances (Drake, et al, 99). According to Podymow, Obstacles to sobriety include psychiatric illness, poor social support, lack of stable housing, duration of addiction and refusal of treatment (Podymow, et al, 6, p. ). Additional complications that promote treatment resistance are a basic mistrust of institutions that provide rehabilitative services. Some individuals are unable and perhaps unwilling to follow the demands of program requirements, preferring the relative freedom of living on the streets. Providing those with chronic addiction stable housing in a client centered, supportive environment with social supports could potentially promote recovery or reduce substance abuse problems. Findings from Housing First Harm Reduction Programs. Research has shown that traditional models of treatment for chronically homeless individuals with alcohol dependence that focus on an abstinence only model are less effective due to the priorities of the program being incongruent with the priorities of the individual. Individuals who view housing as the

6 immediate need and who are unable or unwilling to participate in treatment have obstacles in qualifying for housing programs (Tsemberis, Gulcur, & Nakae, ). Gulcur, Stefanic, Shinn, Tsemberis and Fischer () conducted a study that demonstrated that Housing First programs were more effective and more cost efficient than traditional continuum of care programs in increasing the number of those housed and reducing hospitalization costs for those with psychiatric disabilities and substance abuse issues. These findings are preliminary, and the authors encourage further research in this area in order to demonstrate the most successful outcomes for individuals with a dual diagnosis of mental illness and chemical dependency. One school of thought is that individuals need a stable and secure living environment to have basic needs met before tackling the issues related to getting sober. Housing First programs are designed to alleviate barriers to housing for the most vulnerable homeless individuals (Gulcur et al, ). A supportive housing environment provides a foundation on which to promote harm reduction skills and to encourage sobriety for those who choose it. The harm reduction model within housing seeks to reduce adverse consequences of use while continuing to provide consistent service and housing supports regardless of whether an individual chooses to continue to drink or to pursue sobriety (Tsemberis, Gulcur, & Nakae, ). Glenwood and Anishinabe Wakiagun in Minnesota. In Hennepin County in Minnesota, there are two facilities designated to house those they consider to be chronic inebriates. Glenwood opened its doors in May of 99 and houses 8 men who have had a history of multiple detoxification center (detox) admissions and failure in traditional treatment programs. Anishinabe Wakiagun opened in September of 996, and serves American Indian men and

7 women who have chronic alcoholism. There are residents at Wakiagun, and it is run by Anishinabe Wakiagun Limited Partnership. The emphasis is on housing those exhibiting problems related to excessive alcohol use, evidenced by a high number of detox admissions, multiple unsuccessful chemical dependency treatment attempts, and physical deterioration or homelessness related to alcohol use (Thornquist, ). Glenwood and Anishinabe Wakiagun were evaluated to see whether or not residents were able to reduce their use of detox and other emergency services while living at the residence. Both facilities saw a significant decline in detox admissions for residents while in the programs. It is estimated that there were detox admits saved each year for individuals at a cost of $ per visit, for a total of $9,6. In addition to cost savings, this opened up - percent of the county s detox capacity. If detox facilities are full, intoxicated individuals are brought to emergency rooms where the costs incurred are inherently higher (Hennepin County, ). Emergency room visits were not shown to have a statistically significant decline; however, the cause of admission changed. For those who were not housed, emergency room visits consisted of acute intoxication or injuries resulting from being intoxicated. Those who are housed are likely to continue to need emergency medical services as their alcoholism progresses, particularly if they are suffering from alcohol related medical conditions (Hennepin County, ). Harm Reduction Programs in the Unites States and Canada. There are only a handful of programs in the United States that serve those with chronic alcoholism and that are designed to reduce costs of publicly funded services by utilizing harm reduction strategies. Downtown 6

8 Emergency Services Center s 8 Eastlake project in Seattle, Washington, is a Housing First program serving 7 men and women with chronic alcohol addiction. It was found that by housing those who were homeless with chronic alcoholism they saved an estimated $. million in the first year. These cost savings were due to a % reduction in medical services, % reduction in county jail bookings, 87% reduction in detoxification or sobering centers, and a 9% reduction in shelter stays (Addictive Behaviors Research Center, 8). In addition to saving costs by reducing stays in the above mentioned facilities, the fact that the chronic users of these systems were housed created space for others who may need to utilize a homeless shelter or detox center. Another Housing First program that advocates a harm reduction model is Ottawa s Shephards of Good Hope Murray Street building in Ontario, Canada. This Managed Alcohol Program (MAP) provides its 7 residents a ounce serving of wine per hour from 7: am until : pm (Duffy, 6). The residents have experienced an overall increase in health as well as a reduction in costly services. Police encounters with the individuals involved in the MAP decreased by %, while emergency room visits decreased by 6%. Both participants and their case managers reported that individuals involved in the program showed an improvement in health, nutrition and hygiene. Costs per month for Ottawa s MAP were $77 per client, with a reduction in monthly emergency department, hospital care and police services totaling an average of $7 per client (Podymow, et al, 6). Homelessness in Minnesota and Duluth. The problem of homelessness is on the rise. In Minnesota, an estimated 9, individuals experience homelessness each night (Minnesota Coalition for the Homeless, 8), and this could include many more since counting all of the homeless individuals is not feasible. In St. Louis County, % of individuals who are homeless 7

9 are children under (MCH, 8). More than % of homeless adults have a mental illness and 7% have been discharged from a correctional or human services facility in the last year. In addition, 8% of homeless individuals report having a chronic mental or physical disability that limits work or daily living skills (Ending Homelessness in Ten Committee, 7, p. ). In Duluth, previous attempts to address the problem of homelessness have included the development of shelters, transitional housing and other outreach services for the homeless. These programs only serve to manage the problem of homelessness, and have not been successful in eliminating it. Shelters are often overextended, and there is a time limit on how long a person can stay. There may not be enough time to find employment, financial assistance, or to acquire other income to find an apartment, not to mention purchasing necessary household items and food. Recent surveys have shown a growing number of homeless individuals as well as increases in those who have been homeless long term, or multiple times. It is estimated that only % of homeless individuals in St. Louis County are able to maintain housing without supports, according to the Ending Homelessness in Ten Committee (EHITC, 7). The San Marco Housing Project. The San Marco project is a Housing First model that was in the planning stages for nearly twenty years amid controversy over why a building that allows alcohol consumption should be erected to house chronic alcoholics. A group of individuals saw a need to provide housing to those who have fallen through the cracks and in May of 7 the San Marco opened its doors. The San Marco consists of a board and lodge facility with Single Room Occupancy (SRO) units for those who are chemically dependent and efficiency units to house those who have a history of homelessness or who are at risk of becoming homeless. The two areas are strictly divided with a partition where residents in one side are not allowed to go into the other side. Referrals are offered utilizing a harm reduction model, and 8

10 can include advocacy, medical care, case management, mental health treatment and chemical dependency treatment. This research will focus on the SRO units for those with chronic alcoholism and a history of long term homelessness. There is no time limit on how long an individual is able to reside at the San Marco, provided that they refrain from violence and adhere to the rules set by the organization. Almost all current residents reported previously living on the streets of Duluth, for example near the boardwalk, under bridges and in city parks. Thanks to the vigilant efforts of those who worked to open the doors of the San Marco, formerly homeless individuals now have safe and permanent homes. With housing stability, the hope is that other areas of an individual s life will continue to improve. Significance from a Social Worker, Taxpayer and Humanitarian Perspective Research in utilizing a housing first harm reduction model of care is significant to those in the human services field as there will always be individuals who do not want to abstain from the use of substances, or who are unable to do so. In these cases, traditional abstinence only approaches have proven to be ineffective, resulting in those who are not able to live up to program expectations being terminated from the programs, often to homeless shelters and without any permanent housing options. Additionally, in order to utilize an effective client centered approach, a social worker s responsibility is to meet the client where they are at. Housing is likely the number one priority for those who are chronically homeless. It is perhaps unethical to ask individuals to address their chemical health needs when such basic needs as stable housing and safety are not met. 9

11 Additionally, it is important that we look at providing the most efficient social services possible in order to be cost effective. Now more than ever, funding for human service agencies is limited and focused on outcome. Any taxpaying citizen has an interest in how their dollars are spent and how their public services are utilized. Those in support of the San Marco project hope that it will be a cost saving program that effectively reduces key services for those afflicted by chronic alcoholism and homelessness. Estimated costs for housing the chronically homeless are $, - $, per year, compared to a $, - $, cost on public services for those who are homeless (EHITC, 7). Those who reside at the San Marco are a vulnerable population who had been living in poverty literally on the streets, in parks, under bridges or wherever else they could find shelter. Research has indicated that housing those with chronic alcoholism and homelessness is a cost effective and socially responsible alternative. The results of this study can be used to determine if projects like the San Marco are in fact successful in reducing services used and improving the functioning of those who reside there. This will be helpful in how services are provided, accessing additional funding, or determining whether or not to continue to develop housing options like San Marco in the future. Research Question and Hypothesis For the purposes of this research, the questions posed are:. Is there a reduction in the use of detox services for those currently residing at the San Marco?. Is there an improvement in functioning during the time an individual resides at the San Marco? This study will utilize existing quantitative data and statistical analysis to answer these questions.

12 Methods Population and Sample The research population consists of those previously or currently living at the San Marco. This includes those individuals most likely to die on the streets without intervention due to the severity of their addiction. This means those who are not only chronic alcoholics, but also vulnerable, often with severe medical and mental health problems. The population represents a group that over-utilizes services such as the Center for Alcohol and Drug Treatment s detox unit. Typically, these individuals are adults who have had numerous incidences of homelessness as well as multiple visits to in-patient chemical dependency treatment facilities. The sample will include those individuals who are currently residing at the San Marco as of March, 9. This research project is part of a larger study being conducted by the Center for Community and Regional Research in collaboration with Center City Housing, the Center for Alcohol and Drug Treatment, St. Louis County Public Health and Human Services, and the Department of Social Work at the University of Minnesota, Duluth. For this study, information will be gathered on those who have lived at the San Marco from existing records at the Center for Alcohol and Drug Treatment (CADT) detox center and from the functional assessments conducted every six months by the San Marco staff. The larger study will utilize the above information as well as collaborative information on those previously and currently housed at San Marco from St. Luke s and St. Mary s hospital emergency departments and local police arrest records. Research Design Using a pre-test/post-test pre-experimental design, secondary data analysis was used to determine whether there was a reduction in the use of detox by San Marco residents. A

13 reduction in detox use was defined as any statistically significant decline in the use of this facility as determined by using existing records collected by CADT staff and provided using alpha numeric identifiers. CADT staff provided detox admission data for the year prior to living at San Marco, calculated using a monthly average, compared with visits per month on average after admission. Secondary data was also provided by San Marco staff, via a pre-test post-test preexperimental design that was used to analyze changes in functioning during each resident s stay. Improvement in functioning was determined by using a State of Minnesota Department of Health and Human Services functional assessment form (appendix A). This assessment rated clients on a - scale, where is no problem, is a slight problem, is a moderate problem, is a severe problem, and is an extreme problem. Areas that were assessed included the following:. mental health symptoms. mental health service needs. use of drugs or alcohol. vocational functioning. educational functioning 6. social functioning 7. interpersonal relationships 8. self-care and independent living capacity 9. medical health. dental health. ability to attain and maintain financial assistance. ability to attain and maintain housing. ability to use transportation. ability in other areas Functional assessments are completed by San Marco staff for each resident at intake, 6 months, months, and 8 months. As the San Marco has not been open for two years, the month functional assessment will not be created yet, although San Marco policy is that each resident is

14 evaluated every 6 months as well as at intake and discharge. The current study will compare intake to 6 month and month follow-up. Operational Definitions and Data Collection For the purposes of this study, the definition of homelessness will coincide with the San Marco s definition, which is homeless continuously for one year or longer, or homeless for at least four times in the past three years. Housing first will be defined as viewing housing as the primary need of those individuals who are homeless. Harm reduction is a method of working with those with chronic alcoholism in reducing the amount of alcohol consumed. Harm reduction will focus on alcohol use exclusively, since it is the drug of choice for all residents currently at the San Marco. San Marco staff provided existing data for this research. Each resident was assigned an alpha numeric identifier, and information was provided without names in an effort to maintain anonymity. San Marco staff met with the researcher at the San Marco and provided data from resident files that was collected and entered into an excel spreadsheet. This data included demographic information, detox records and functional assessment ratings. Demographic and functional assessment information was collected by San Marco staff. Detox records were provided by the CADT s director to San Marco staff and subsequently passed onto the researcher. The researcher collected information, coded it and entered it into a spreadsheet for further analysis. Data analysis Quantitative data analysis using SPSS was utilized in order to determine if the results were significant, illustrated by a statistically significant reduction in the amount of detox visits

15 for each resident and an increase in functioning according to the assessment tool. A matched pair t-test was used to analyze detox admissions during the year prior to living at San Marco compared to the detox admissions during the first year of residency. Since some residents have not been at the San Marco for a full year, a monthly average was calculated to compare prior detox admissions to those during residency. To determine the functioning of each resident, data gathered at intake and at six and twelve months afterward using a category functional assessment tool was analyzed. The Wilcoxon signed ranks test was used in order to determine if functioning had improved significantly over time according to the functional assessment ratings. Results Demographics Of the residents currently living at the San Marco who were studied, 9 had lived in Duluth for the past months, with one resident living in Duluth for the previous 9 months. There were 6 individuals who identified as being white and who identified as American Indian or Alaskan Native. Ethnicity for individual was Hispanic, and 9 Non-Hispanic. At intake, individuals reported that they had a mental illness, whereas 6 stated that they did not. These individuals were categorized as having a dual diagnosis of both mental illness and chemical dependency. However, according to San Marco staff, many mental health issues were not reported at intake although diagnosed during residency. There were individuals out of who reported a physical disability, and out of who reported being diagnosed with a

16 Traumatic Brain Injury. No individuals identified as being developmentally disabled, although one individual had a mobility impairment, and two had vision impairments. There were males and 6 females living at San Marco during the time of this study. This group included 8 veterans. All residents reported that alcohol was their drug of choice, and none reported any recent drug abuse. The number of in-patient chemical dependency treatments ranged from to per resident. When residents were asked where they had lived over the last years, all residents reported living in a place that was not meant for habitation, such as outside. There were residents who reported using emergency shelters, who had lived in group homes, and who reported living with friends. Other individuals had rented apartments (6), lived with family (), lived at a motel (), or stayed at a psychiatric hospital (). Reduction in the Number of Detox Stays A paired sample t-test was used to analyze the detox data (see Table ). The mean number of detox admissions for an individual in the months prior to living at San Marco was. stays per month. Average detox admissions during residency at the San Marco was.6 per month. Results demonstrated a significant reduction in detox admissions (t=.6; df=8; p<.). The results indicate that there is an 89% decrease in the number of detox stays for residents at the San Marco.

17 Table : Detox Costs Detox Costs Average detox visits per month Average detox visits per year Days spent in detox per year* Each resident s cost for days** Total cost for all residents Months Prior to San Marco. 8 6 $9,6 $8,8 Months During San Marco Residence.6 $, $, Cost Savings $8,9 $9,6 * days per visit **$6 per day Improvement in Functioning Functional assessment results were analyzed using the Wilcoxon Signed Ranks Test. The Wilcoxon Signed Ranks Test demonstrated a statistically significant improvement in functioning in seven out of thirteen areas at the. level from intake to six months as well as from intake to twelve month time periods (see Table ). These areas include ) the use of drugs or alcohol, ) social functioning, ) interpersonal functioning, ) self care and independent living capacity, ) dental health, 6) obtaining and maintaining financial assistance, and 7) obtaining and maintaining housing. Two areas did not show significant improvement in six months, although did at twelve months. These areas are mental health service needs, which improved at the. level at twelve months and medical health which improved at the. level at twelve months. 6

18 Areas of functioning that did not show significant improvement were mental health symptoms, vocational functioning, educational functioning, and using transportation. Functional assessment item other area, was not included in the analysis as there was no data entered on any of the current residents. Results from the six month to twelve month FAs were significant in only the ability to obtain and maintain housing. Table below gives the rating number, how many individuals are at each rating at the initial functional assessment (FA), how many individuals are at each rating at the six month FA, and the amount of change in each area. The change from initial FA to six month FA is indicated in the shaded box for the residents who have been at the San Marco for at least six months. Next, the table illustrates the initial FA ratings, the twelve month FA ratings, and the amount of change from intake to twelve months for the residents who have been at the San Marco for at least twelve months. Out of residents, were there for over six months and were there for twelve months; therefore the table represents only these individuals as there was not enough information for residents that had only had an initial FA. Table indicates those individuals whose data has changed. For example, in function, 8 people moved from a () extreme problem to either a () severe or a () moderate problem, as indicated by the 7 individuals who were added to the level rating and the individual added to the rating category at the six month FA. Additionally, in function, there was one individual who moved from a to a, which indicated no significant improvement in functioning at the twelve month FA (see appendix for a more detailed representation of the functional assessment areas). 7

19 Table : Functional Assessment Data Frequency Table Rating* Initial Functional Assessment (FA) N= Six month FA N= Change initial to six months N= Initial FA N= Twelve month FA N= Change initial to twelve months N=. Mental health symptoms n.s n.s.. Mental health service needs n.s p<.. Use of drugs or alcohol p< p<.. Vocational functioning n.s n.s.. Educational functioning n.s n.s. 6. Social functioning, including use of leisure time p< p<. 8

20 Frequency Table Rating* Initial Functional Assessment (FA) N= Six month FA N= Change initial to six months N= Initial FA N= Twelve month FA N= Change initial to twelve months N= 7. Interpersonal functioning, including relationships with family p< p<. 8. Self-care and independent living capacity p< p<. 9. Medical health n.s p<.. Dental health p< p<.. Obtaining and maintaining financial assistance p< p<.. Obtaining and maintaining housing p< p<.. Using transportation n.s. + - n.s. *= no problem, =slight problem, =moderate problem, =severe problem, =extreme problem 9

21 Discussion Interpretation of Results Results demonstrated a significant decrease in the number of detox stays for residents of the San Marco. The average number of visits to detox in the year prior to living there was. per month, or about 8 visits per year, and this number was reduced to.6 visits per month, or about visits per year. According to the CADT staff, one visit to detox on average lasts about two days, at a cost of around $6 per day, or $ per visit. As Table demonstrates, the average cost for one resident visiting detox 8 times in a year would be approximately 6 days spent in detox, for a total cost of $9,6 for each resident. Multiplying this by residents, the total average detox cost for all residents would be $8,8. In comparison,.6 visits per month would amount to about visits to detox per month and detox days, for a total cost of $, per resident or a total of $, for all residents. Using these figures, an estimated $8,9 was saved per resident, or $9,6 for all residents. This is comparable to Hennepin County s Glenwood and Anishinable Wakiagun, which saved $9,6 in detox costs in one year (Hennepin County, ). It should be noted that the cost for detox services in Hennepin county is higher, at $ per day as compared to $6 per day in this study. Seven out of thirteen levels of functioning improved after only six months, demonstrating the effectiveness of the program. Two additional areas showed improvement from intake to twelve months, showing that in one year, nine out of thirteen levels of functioning showed significant improvement. Area, which indicates use of drugs or alcohol, showed significant improvement. All residents listed alcohol as their drug of choice, and the severity of this problem decreased significantly.

22 Other areas that improved significantly were mental health service needs, social functioning, including use of leisure time, interpersonal functioning, including relationships with the adult s family, self-care and independent living capacity, medical health, dental health, obtaining and maintaining financial assistance, and obtaining and maintaining housing. These improvements lead one to believe that individuals residing at the San Marco are getting help for mental health difficulties, keeping in mind that nearly all of the residents have a dual diagnosis of mental health and chemical dependency issues. Although some did not have a mental health diagnosis at intake, San Marco staff ensure that those who are in need of help and are willing to accept it are diagnosed and offered treatment. Social functioning, interpersonal functioning and self-care, as well as the capacity to be more independent, are improvements that likely lead to an improved ability to function in the community and to experience fewer conflicts with others. A lack of social support or an antisocial support system as well as a lack of independent living skills has been shown to be an obstacle in the ability to maintain sobriety and subsequently housing (Drake et al, 99; Podymow, et al, 6). The San Marco appears to have been successful in providing a supportive atmosphere where these areas of functioning improve. Somewhat surprising is the fact that individual s medical health showed improvement from intake to twelve months. Other studies have indicated that this is a difficult area to improve due to the debilitating effects of alcoholism on an individual s physical health. For example, Hennepin County s facilities did not show a significant decline in emergency room visits, although the cause of admission changed from those visits caring for acute intoxication or alcohol related injuries to those medical services needed to address problems related to the

23 progressive nature of alcoholism (Hennepin County, ). This study analyzes medical problems only on the functional assessment form, and not data collected from the local emergency room, which may provide different results. The San Marco study supports previous research conducted by Larimer et al (9) that has demonstrated that housing first programs have lead to increased stability with improvements in life circumstances. The Larimer study also demonstrated a decline in drinking behavior despite no requirements for abstinence and a significant cost reduction in the use of detoxification services, emergency room services, hospital visits and criminal justice services. Future research that is planned for the San Marco will look at emergency room visits and costs as well as arrests records and police involvement for those residing at the San Marco. Those areas that did not indicate significant improvements in this study were mental health symptoms, vocational functioning, educational functioning and using transportation. It would be difficult to create a reduction in mental health symptoms, although perhaps it would be a good idea to measure an individual s ability to cope with mental health symptoms. Similarly, for a person dealing with chronic alcoholism and homelessness, it would be quite a success story if a person was able to successfully work or go back to school after only 6 or months of being housed. However, these areas should be promoted if a resident is able to manage their alcoholism. San Marco staff report that there are some individuals who do improve to the point of being able to move into an independent living environment. From a social worker s perspective, it is helpful to recognize that there are some individuals who do not wish to quit drinking, or who are unable to do so. This research indicates that one way to help improve an individual s functioning is to stop attempting to push abstinence

24 on those who do not want it. Instead, allowing the person to reside in an environment that does not completely restrict use while encouraging harm reduction has appeared to have both cost saving benefits as well as helped residents improve their functioning in many areas. Limitations One limitation of this study is that those who are brought to detox by the police may be determined by current law enforcement policy. There may be periods of time when homeless individuals or those living at the San Marco are more likely to encounter officers and be brought to detox, for example drinking in the parks in the summer months. Additionally, San Marco staff have reported that police officers may bring the individual home to San Marco, rather than bringing the person to detox. However, any reduction in detox services is seen as a cost saving measure and should be considered an improvement. Functional assessments are typically conducted at intake, then every six months during an individual s residency at the San Marco. In the initial intake appointment, residents may not disclose certain problems in functioning if they are homeless and eager to find a place to live. Therefore, there may be a decrease in the level of functioning once an individual is able to be more honest about their situation and staff is able to get to know the resident better. Also, the functional assessments are somewhat subjective measures, and there is a potential for bias on behalf of San Marco staff if the goal is to show an improvement in functioning. Despite these potential limitations, there was a notable difference in the ratings on the functional assessment. This study used secondary data, collected by others then provided to the researcher. Any time secondary data is used, the research can be questioned since the researcher is not able to control how data was collected or to check the accuracy of the data. However, at the San Marco,

25 the person who completes the functional assessments is one of the directors who often knows the residents well prior to admission and is likely to obtain accurate information. Detox records are concrete data simply showing how many admits a person has prior to and while living at San Marco. Additionally, there is the risk that the changes in functioning or in the level of detox admissions could have alternative explanations for improvements that took place with the pretest/post test data. Changes in law enforcement policy may dictate the how severely individuals are targeted for such crimes as public drunkenness or open container laws. Additionally, the summer tourist season in Duluth could be a time where law enforcement are more likely to arrest those drinking on the downtown lakewalk, or this may simply be a time where people drinking in public are more noticeable and subsequently fined or taken to detox. If an individual moves into the San Marco and abides by the rules of more restricted alcohol use, this could be the reason for improvements in several areas of functioning, and it s difficult to determine exactly what the root cause of improvements is. Perhaps it s a combination of factors. At any rate, it is hopeful to see that individuals are improving, leading to a decrease in many problems for both the individuals and the community. Recommendations for Future Research This research is part of a larger study that measures outcomes in additional areas, including data related to emergency room visits as well as arrest records. The larger study will look at data in the year prior to living at the San Marco, data while living there, and data after an individual leaves. Detox data will also be analyzed for those who have left San Marco, to see if their use of this facility has increased or decreased after leaving the residence. This information

26 will measure cost savings measures as well as the health and behaviors of those residing at San Marco to see if there is any reduction in savings or additional improvements in social functioning. It is also recommended that this research continue as additional individuals reside at the San Marco in order to see if there other improvements in functioning over time. It is hopeful that results are significant after only six or twelve months, and long term studies could be helpful in determining additional improvements. It would also be helpful to find additional areas that are able to be measured or additional measurement tools in order to determine if these results are confirmed or not. Summary and Conclusions This study has shown that individuals residing at the San Marco have reduced the number of days spent at detox by 89%, demonstrating a nearly $, cost savings while simultaneously opening up space for others who may need detoxification services. Additionally, residents have shown a significant improvement in most areas of functioning according to the functional assessment tool. Most notable are the reduction in problems related to alcohol use, social functioning, interpersonal skills, independent living skills, medical and dental health, and the ability to maintain stable housing. Maintaining stable housing for individuals with a history of chronic alcoholism and homelessness was the main priority, and these results demonstrate statistically significant results in the ability to attain and maintain housing at all intervals evaluated. The literature illustrated that working with those who are homeless with chronic alcoholism has been a challenge. Some individuals may have a desire for sobriety, whereas

27 others do not. Still others may be incapable of attaining sobriety despite multiple attempts. Individuals with a dual diagnosis have additional obstacles when trying to cope with mental health symptoms as well as chemical dependency. Many who are homeless are also afflicted with mental health and/or chemical dependency issues. The homeless often represent vulnerable segments of the population, and those who have multiple impairments face multiple obstacles in finding housing and maintaining stability. The San Marco utilizes a housing first harm reduction model in an attempt to provide and maintain a safe and stable living environment for those who are most considered most vulnerable due to their impairments. These individuals are often not able to live in traditional board and lodge facilities that have requirements for sobriety. Since living on the streets is often associated with the increased use of facilities such as detox centers and emergency room visits, it may be cost effective to instead channel these funds into providing these individuals with stable housing. In addition to saving costs, housing chronically homeless alcoholic individuals is the right thing to do from a humanitarian perspective. There is currently a commitment by a group of individuals in Duluth to work to end homelessness. Residences such as the San Marco may be the only realistic option for some individuals to obtain and maintain housing stability. In addition to being housed, individuals have shown to improve in many areas of functioning, which is an indication of success for this program. With additional research, housing options similar to the San Marco may be the answer for many homeless individuals unable to live in more restrictive board and lodge settings. 6

28 References Addictive Behaviors Research Center. (8, January ). 8 Eastlake: First-Year Preliminary Findings. Retrieved January 9, 9, from Downtown Emergency Service Center: Barak, G. (99). Gimme Shelter: A Social History of Homelessness in Contemporary America. Westport: Praeger Publishers. Bassuk, E., Rubin, L., & Lauriat, A. (98). Is homelessness a mental health problem? American Journal of Psychology, Vol., No., 6-. Drake, R. E., Osher, F. C., & Wallach, M. A. (99). Homelessness and Dual Diagnosis. American Psychologist,Vol. 6, No., 9-8. Duffy, A. (6, January ). How Some Homeless Alcoholics are Drinking Their Way to Good Health. Retrieved January, 9, from Ending Homelessness in Ten Committee. (7, March). Heading Home St. Louis County; A Ten-Year Plan to End Homelessness. Duluth, MN. Gulcur, L., Stefanic, A., Shinn, M., Tsemberis, S., & Fischer, S. N. (). Housing, Hospitalization, and Cost Outcomes for Homeless Individuals with Psychiatric Disabilities Participating in Continuum of Care and Housing First Programmes. Journal of Community Applied Social Psychology, Hennepin County. (). Hennepin County's Housing for Chronic Inebriates Analysis. Hennepin County. Larimer, M., Malone, D., Garner, M., Atkins, D., Burlingham, B., Lonczak, H., et al. (9). Health Care and Public Service Use and Costs Before and After Provision of Housing for Chornically Homeless Persons With Severe Alcohol Problems. Journal of the American Medical Association, Vo.l, No., 9-6. Miles, B. (, April). New Trends in Local Homeless Policies: A Phenomenological Study of Homeless Experiences. Dissertation Abstracts International, A: The Humanities and Social Sciences, vol. 6, no.. Minnesota Coalition for the Homeless. (8, September 7). Homelessness in Minnesota. Retrieved December, 8, from 7

29 National Association of Social Workers. (9). Code of Ethics. Retrieved March 9, 9, from NASW: Orwin, R. G., Garrison-Mogren, R., Jacobs, M. L., & Sonnefeld, L. J. (999). Retention of Homeless Clients in Substance Abuse Treatment: Findings From the National Institute on Alcohol Abuse and Alcoholism Cooperative Agreement Program. Journal of Substance abuse Treatment, Vol. 7, -66. Podymow, T., Turnbull, J., Coyle, D., Yetisi, E., & Wells, G. (6). Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ: Canadian Medical Association Journal, Vol. 7, -9. Tam, T. W., Zlotnick, C., & Robertson, M. J. (). Longitudinal perspective: adverse childhood events, substance use, and labor force participation among homeless adults. American Journal of Drug and Alcohol Abuse, Vol. 9, No., Thornquist, L. (, March). Anishinable Wakiagun Residents' Use of Emergency Services in Hennepin County, Minnesota. Retrieved March, 9, from f Tsemberis, S., Gulcur, L., & Nakae, M. (). Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis. American Journal of Public Health, Vol. 9 No.,