Outreach programs to people who are homeless encompass a wide variety of models (17). In terms of service orientation, however, their engagement hovers between opposite conceptual poles marked by the degree to which they employ negotiation, leverage, and coercive measures. Commonly, at one end are mental health street outreach teams composed of nonmedical professionals and, often, paraprofessionals, whose role is to seek out and methodically engage people living in public spaces or transitional environments, such as shelters and drop-in centers. These personnel rely on incentives to concrete services and care. Clinically, their interactions are often supportive or motivational in nature. Engagement is usually a gradual and often painstaking process—taking from weeks to many months—and outreach clinicians confront severe mental illness and chemical misuse as they gain the trust of people who are by definition severely socially disaffiliated (18). In many communities, their work can be encumbered by systems limitations, inhibiting the continuous care that encourages recovery. Foremost among the limitations is a lack of affordable housing, the essential ingredient to solving homelessness.

At the other conceptual pole is a variant of street outreach that more closely resembles classic mobile crisis services. Staffed by professionals, including psychiatric consultants, these teams have the capacity to involuntarily transport people to an emergency room. Depending on the service system of which they are a part, such teams may be assigned an exclusively crisis role, receiving referrals for people viewed to be in particular distress from the concerned public, other outreach teams, or other providers (19). Alternatively, some localities’ street teams have a dual role of outreach and emergency intervention. Examples of these are assertive community treatment (ACT) teams, which offer comprehensive rehabilitation and treatment in a flexible manner (20).

In other communities, prehospital emergency intervention may fall by default to law enforcement agencies. Police officials increasingly understand that there is a need to train officers to effectively manage emotionally disturbed persons; evidence shows that unless police have significant additional mental health support, the distressed people with mental illness they encounter are disproportionately arrested rather than being diverted into the mental health system (21). One diversion intervention that has gained attention consists of a team of specially trained police officers that is dispatched to a behavioral health incident to assess and transport a person to an emergency department (ED) with which the team has formal linkage. This collaborative intervention, also known as the Memphis model, has been shown to decrease inappropriate use of police and jail resources (22).

Consistent with this spectrum of approach is the historical debate among professionals and advocates concerning the differential application of coercive and noncoercive approaches in long-term rehabilitative engagement. Some argue that the trauma of involuntary transport and hospitalization serves to further alienate homeless individuals and creates an impediment to recovery and rehabilitation, whereas other advocates cite the lifesaving measures that emergency-oriented services can offer.

There is almost no research comparing outcomes for either position with respect to successful long-term introduction to services, especially in the context of acute involuntary measures. A 1993 qualitative analysis of a project combining involuntary transport of people living on the street and commitment to acute, and then intermediate, hospitalization yielded mixed outcomes. In this New York City program, 27% of homeless acute inpatients were discharged to stable domiciliary environments, and 67% were transferred to a state hospital for intermediate care (23). In turn, of patients who were transferred, 29% were lost to follow-up via elopement or discharge against medical advice (24). Both individual engagement issues and systems limitations, especially a dearth of housing, may have engendered relatively high dropout rates.

Although science has yet to illuminate differential clinical and social variables that point to the effectiveness of either pole within the coercion spectrum, it is intuitively rational that either can be successful for different individuals, even at different moments in their lives. Experience informs us that opportunities for dramatic shifts in rehabilitative engagement occur during points of human crisis, when psychosocial equilibrium
is disturbed. In such cases, sensitive clinicians understand when to employ an incentive or when to intervene even in the absence of a person’s volition. Prehospital crisis services commonly make these determinations (17). Dyches et al. (25) retrospectively examined the effectiveness of Cleve-land, Ohio’s, community-based mobile crisis service by comparing users of this service with a matched sample of ED patients. People not already connected to mental health service providers were more likely to receive community mental health follow-up within 90 days. Compared with the ED group, mobile crisis service recipients were also more likely to be homeless and have serious mental illness. An extension of this study also indicated that mobile crisis contacts were less likely to be hospitalized (26), a finding consistent with other studies of mobile crisis services (27).

As noted earlier, homeless persons use ED services of all kinds disproportionately. In one large-scale epidemiologic survey, Kushel et al. (28) reported that almost one in every three homeless people visit a general ED in a given year, three times the rate of the general population (29). In another study drawing on a sample in San Francisco, 55% of all reported ED encounters in a 1-year period were made by the 7.9% of homeless respondents who used the ED four or more times (29).

The frequency with which ED staff actually encounter patients who are homeless depends on local community prevalence. In one large urban public hospital located near a shelter, between 20% and 30% of annual visits were noted to be of homeless individuals (30). Even among encounters with people who were homeless in this general ED that did not present with a psychiatric chief complaint, histories of behavioral health problems were significantly greater than among nonhomeless controls: 81% with alcohol problems, 70% with depression, and 27% with apparent schizophrenia (31).

In urban psychiatric emergency services (PESs), the numbers of encounters with homeless people are substantial as well. McNeil and Binder (1) surveyed a public hospital in San Francisco and reported that 30% of contacts were with people who were homeless and that these patients were more likely than the nonhomeless to have multiple contacts. This study also reported that patients who were homeless and mentally ill were more frequently hospitalized, with a tenuous connection to outpatient services that resulted in a costly cycle of acute psychiatric admission and discharge. A study of 10,340 patients in the San Diego mental health system revealed that patients with homelessness used emergency, crisis residential, and inpatient services at steeply higher rates than their nonhomeless counterparts, while participating in significantly fewer outpatient, day treatment, and case management services (32).

Several investigators have explored predictors of ED use among people who are homeless. Chemical misuse is noteworthy. One study of homeless individuals with chronic public intoxication noted that the ED is their most frequent health care contact (33). In the sample of Kushel et al. (29), surveyed from 1996 to 1997, chemical misuse in the past year was strongly associated with ED use and multiple encounters. McNeil and Binder (1) echoed this by noting that the most frequent PES users in their study were homeless people with co-occurring chemical misuse and mental illness. However, in a 1987 sample taken from the public shelter system in New York City, substance dependence and alcoholism were insignificant and negative predictors in ED appearance, respectively (34). The discrepancy may result from a number of causes, including a general increase in chemical misuse among homeless populations, contemporaneously less aggressive health care outreach and transport by law enforcement and crisis services, and the possibility that a particular cluster of high-risk factors may augur repeat encounters with emergency services. Additional factors among people who are homeless may include concurrent mental illness, chronicity of homelessness, medical comorbidities, victimization, arrest history, and history of violence (1,29,34).

The emergency department as “primary provider” has also been linked to issues of poverty and disaffiliation in general, of which homelessness is an extreme phase. A perception of meager to nil social support is linked to homelessness (35,36). Patients who are homeless have, in turn, been critical of ED staff behaviors (37

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