The following is the executive summary of a rapid review on assertive outreach with women experiencing homelessness by Tamara Blakemore, Joel McGregor and me. The review was done as part of a research project we are doing in partnership with Nova for Women and Children. The full report is available from here.
The aim of this rapid review was to identify key themes in the existing literature that could help develop a specialist assertive outreach program for women experiencing homelessness in the Hunter region of NSW. Rapid reviews are a relatively quick, but structured, approach to finding and synthesising evidence from research and other literature and are particularly suited to policy and practice contexts (Featherstone et al., 2015). This review identified 30 key sources that discussed assertive outreach approaches for working with homelessness that were culturally relevant and did not exclude women. These sources were then analysed for key narratives and themes.
Assertive outreach practice is distinguished by the situations and settings in which workers come into contact with, and continue their work with, clients. In practice, assertive outreach often means taking our work to people, working with them where they are at and prioritising client preference and pace in our work. It is worthwhile noting here that assertive outreach approaches are often used with people for whom homelessness has become a chronic or cyclic process – rather than a situational crisis where different responses to homelessness may be more appropriate. In Australia, there has been a revival of interest in outreach with homeless people, with a particular emphasis on assertive outreach, since 2008 and the release of the White Paper, The Road Home: A national approach to reducing homelessness (Homelessness Taskforce, 2008).
Phillips et al. (2011) and Homelessness NSW (2017b) suggest there are several differences between ‘traditional’ outreach with homeless people and ‘contemporary’ assertive outreach which has been the focus in Australia since the White Paper. For both approaches, ‘service delivery takes place within the service user’s environment rather than requiring service users to attend a designated service centre’ (Phillips et al., 2011, p. 15). ‘Traditional’ outreach approaches often provide a street-based continuum of care to those sleeping rough including providing clothing, food, and emergency relief; facilitating access to counselling, alcohol, and other drug services; and assisting with referrals to shelters or accommodation. By comparison, Phillips et al. (2011, see also Homelessness NSW, 2017b), highlight ‘contemporary’ assertive outreach methods as much more explicitly focused on securing housing for those sleeping rough. Three distinctive features of contemporary models include: the aim to end homelessness rather than simply supporting people who sleep rough; services adopting an integrated, multidisciplinary approach, to attend to the needs and potential root causes of homelessness, as well as a more ‘persistent’ approach providing sustained resources to people who are homeless and to support them to move into, and sustain, stable housing often with wrap-around support.
It is important to note that efforts to end homelessness are always dependent on housing options being available. If assertive outreach teams, particularly those working from a contemporary model of work, cannot access emergency and longer-term housing, then the goal of ending homelessness is extremely difficult, if not impossible (Coleman et al., 2013; Homeless NSW, 2017; Mackie et al 2019; Phillips et al., 2011). Mackie et al. (2019) go as far as suggesting that assertive outreach is ‘potentially unethical if it is not accompanied by a meaningful and suitable accommodation offer’ (pp. 88-89).
Narrative synthesis of the literature noted key themes that largely coalesce around the intersecting concepts of people and practice in place. Key themes that relate to people include: the attributes of assertive outreach workers, safety, and the unsettling silence of the voices of those experiencing homelessness in the existing evidence base for practice. Key themes that relate to practice, including engagement, models of assertive outreach, principles of practice, and interagency collaboration, are all relevant to working with women.
The reviewed literature emphasised the need for skilled assertive outreach workers who had the ability to build and sustain rapport to connect and work with people in difficult situations, who were willing to undertake practical tasks, and who displayed sensitivity and genuine care. Workers who bring to their assertive outreach roles qualities of ‘flexibility; curiosity; openness; reflexivity; a strong professional orientation and clear framework; bravery; and a service orientation’ are suggested by Coleman and colleagues (2013, p.54) to be particularly effective. But the authors also argue, these worker attributes are not necessarily personality traits but instead work practices influenced by the context and nature of outreach work. They argue that workers’ capacity to enact these behaviours are the result of ‘a sensible and astute reading of the context and their place in it as outreach workers’ (p. 54).
The safety of workers is discussed in the literature in terms of risk management and the ways that models of practice, and service offers, need to be structured in order to protect the safety of outreach workers. Homeless NSW (2017b) emphasises the importance of risk management, including effective staff induction, careful planning, completing environment assessments, being well equipped, working in pairs, and access to supervision. The safety of clients is discussed in terms of harm minimisation strategies and ways to keep people experiencing homelessness relatively safe and well without having access to safe and secure housing. The literature notes a particular focus on the safety of people experiencing homelessness, especially in terms of drug use, mental health and sleeping rough. Middendorp and Hollows (2007) suggest that, ‘sound outreach work with people experiencing primary homelessness operates on a harm minimisation basis—fostering safe and respectful outcomes for clients whatever living situation they are in’, including ‘unpalatable as it may sound’ helping people to ‘sleep rough in safety’ (p. 37). A gap in literature appears to be in the discussion of how to protect the safety of people experiencing homelessness when assertive outreach workers enter their ‘safe’ space. As Middendorp and Hollows (2007) suggest, ‘Outreach workers are constantly mindful that when they make contact with a person sleeping in a squat or in a park, they had better have a good reason to approach them. A key critical reflection question is: what do workers have to offer clients?’ (p. 37).
The voice of people experiencing homelessness, and especially those of women, was largely missing in the reviewed literature. Only two of the research papers spoke directly with people experiencing homelessness. Possibly related to the lack of the voice of people with lived experience of homelessness in the literature, there was also little discussion about the role of self-agency and choice. People experiencing homelessness can, and do, make decisions about their housing options: decisions often constrained by circumstance, capacity and context, but still decisions that should be recognised and respected by service providers (Coleman et al., 2013; valentine et al., 2020). The challenge for assertive outreach is to recognise and build on the ability of people to make decisions and to support the capacity for choices that are constructive to their wellbeing in the short and long term (Coleman et al., 2013; Middendorp & Hollows, 2007; Parsell et al., 2013; valentine et al., 2020).
Engagement is suggested to be central to assertive outreach, as it is often used to support people whose experience of homelessness is chronic or protracted and who may have ‘fallen through the net’ (Tonybee & Allen, 2009, p. 26). Indeed, the model of assertive outreach is sometimes described as an approach to working with people who are ‘difficult to engage’ or ‘hard to reach’ (see for example Addis & Gamble, 2004; Coleman et al., 2013; Firn 2007; Lloyd 2010, et al., 2010; Phillips et at., 2011; Priebe et al., 2005; Rot de Vries et al., 2011). This narrative is problematic and can place the responsibility for service engagement on vulnerable clients and may minimise or hide the ways that services can also be ‘hard to reach’ and difficult to access (Crozier & Davies, 2013; McDonald, 2010).
Indeed, the discussion of engagement, highlights its time intensive nature — a distinctly service oriented issue. Workers may need many attempts to locate or contact a person sleeping rough, to build enough trust to engage the client with the service offer, and to persist with the client through cycles of engagement and disengagement that are likely to be influenced by situations and circumstances outside the control of the worker and agency. For practitioners to have the time required to effectively engage with clients, Addis and Gamble (2004) argue that reduced caseloads need to be a protected part of the assertive outreach model of practice. Of course, reduced caseloads are largely dependent on funding conditions, demonstrating the importance of recognising the broader context of assertive outreach. The time and pace of practice also, inherently, needs to be led by clients if it is to be person-centred and responsive to the lives of women. Being person-centred and client-led, where people experiencing homelessness exercise choice and self-determination and where practitioners avoid coercion (Phillips & Parsell, 2012), can be challenging and raise dilemmas for workers. This raises an important point of reflection for assertive outreach workers in contemplating how ‘person-centred’ their work is, and how effective their outcomes are, if the pace and focus of work is determined by the practitioner rather than the client.
Across the reviewed literature, few sources specifically focused on models of practice with women experiencing homelessness. Literature on models of practice were highly descriptive, meaning there is no definitive evidence for efficacy for particular models or practice approaches (with either men or women). One exception to the male dominated examples provided in the literature, but still heavily descriptive was the brief discussion of the Outreach Allied Health (OAH) team at Central City Community Health Service in Melbourne by Whitelock and colleagues (2015). This program, and its model of assertive outreach practice, had a particular focus on women who were currently homeless. The model involved taking a health service offer to the community including places women slept rough, but also to services and supports where women accessed emergency housing and meal services. The OAH assertive outreach model ran alongside the existing service offer of more traditional, centre and appointment-based engagement, with different staff involved in each service offer. The two service offers interacted by outreach workers being able to make appointments for outreach clients with the centre-based service through warm handover and ready assurance of same-day or within-the-week attention to health needs. The approach focused on building relationships and ‘consistent with trauma-informed care’ (p. 50), sensitivity to the need for longer appointments, and time for clients to safely discuss their needs. It also included specialised staff training in areas such as working with challenging behaviour (responding to people with mental health issues, who are affected by drug and alcohol use, or who have a history of using violence), a proactive response to client disengagement, practical support and assistance, and flexible administrative procedures.
The literature search identified a number of sources that discuss features of successful assertive outreach practice, or key principles of practice where practice happens, what its focus and objectives should be, and what the practice involves, looks and feels like. Some sources reviewed focused on factors related to physical aspects and contexts, others provided aspirational and humanitarian-based principles to guide work. Drilling down to a more concrete approach, Homelessness NSW (2017a, 2017b) suggests nine principles they argue are ‘critical to effective practice when delivering assertive outreach to people who are sleeping rough’ (Homelessness NSW, 2017a, p.11). These practice principles include being trauma informed, culturally sensitive and person-centred, supporting harm reduction, being built on honest communication, being persistent, consistent and flexible, and collaborative.
Interagency collaboration and integrated, multidisciplinary approaches (Homeless NSW, 2017b; Phillips et al., 2011) are a key feature of contemporary assertive outreach with people experiencing homelessness. Suggested models for interagency collaboration have included those which draw on principles of collective impact and include a shared and common agenda, common metrics for the measurement of progress, mutually reinforcing activities for partners, continuous communication, and a crucial key centralising, hub or backbone organisation. Collective impact approaches were used by the Sydney Homelessness Assertive Outreach Response Team (HART) to increase the likelihood that all organisations involved in the project were working towards the collective agenda. The HART model, building on collective impact, is built on the assumption that no single organisation can tackle homelessness, rather, the most effective model is a common agenda. Working in partnership with other organisations can have many benefits, but also render significant challenges. In the context of homelessness, there can be challenges for organisations around sharing case notes and balancing the right to confidentiality with the value of sharing information between services (Brewer et al., 2016; Homelessness NSW, 2017b). The reality of collective impact frameworks and cooperative, coordinated approaches to interagency collaboration is always an underlying tension informed by competitive tendering processes for service funding. Local cooperative agreements have sometimes supported services to work together outside of these agreements.
While the reviewed literature is highly descriptive of existing models of work and (hence) largely not focused on female experience, there are hints as to what effective assertive outreach with women might look like. Collectively, these point to the need for assertive outreach for women experiencing homelessness to prioritise safety, connection, coping, persistence, consistency, and flexibility. These six factors are consistent with a trauma-informed approach to assertive outreach and are consistent with person-centred approaches sensitive to concurrent and cumulative trauma, disadvantage, and adversity. Whether these principles of practice are substantively different to those that could (or should) be adopted for work with men experiencing homelessness is debatable. In many ways these practice principles characterise good practice, across contexts, that is sensitive and responsive to the needs of vulnerable people. What might differ, however, is the application of these principles of practice to a model of assertive outreach for women. It is important to think about how these principles of practice could be ‘operationalised’: what that would look like in practice, who it would involve and where it would occur. There is a strong argument for this information to be gathered from women themselves and from practitioners who support them to maximise the value and fit of service offers to local contexts. Positioning women who have experienced homelessness, and the workers that support them as key informants in the design and development of models of assertive outreach addressing women’s experience of homelessness (and publishing on this work) will address a key gap in this report. While the evidence reviewed provides a scaffolding framework, particularly for key practice principles for assertive outreach work, gaps in the existing evidence will be well complemented by attention to local experiences, wisdom, and knowledge.
NOTE: The references are in the full report.
Blakemore, T., Stuart, G. & McGregor, J. (2021). Assertive Outreach with Women Experiencing Homelessness: A rapid review of the literature. University of Newcastle. http://hdl.handle.net/1959.13/1427125
The research reference group for the research was: Kelly Hansen, Louise Dean, Lee Liewes, Kate Davies, Janine Johnston, Loreen Smith, Alison Porter, Nadine Street
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