The International Journal of Psychosocial Rehabilitation

Healing and Hope for the Homeless: An Evaluation of Project Excell


Medha Talpade

Clark Atlanta University

Salil Talpade
University of West Georgia

Barbara Lattimore
Fulton County Department of Behavioral Health and Developmental Disorders


Author Note:
Medha Talpade, Ph.D. is Associate Professor of Psychology.  As the external evaluator of the project, her contribution to this manuscript included data collection, data mining, analyses, and report writing. Salil Talpade, Ph.D. is Professor and Chair of Marketing and Business Education.  He provided direction into analyses of the data and editing/writing/converting reports into this manuscript.  Barbara Lattimore, Ph.D. is the Director (Retired) of Behavioral Health and Developmental Disorders, Fulton county, Georgia, provided the blueprint for the rationale and initiation of Project Excell.



Citation:

Talpade M, Talpade S & Lattimore B (2010). Healing and Hope for the Homeless: An Evaluation of
 Project Excell
. International Journal of Psychosocial Rehabilitation. Vol 15(1) 25-37

Funding:
This project was funded by SAMHSA, Grant no. TI019647. 

 Correspondence:
 Dr. M. Talpade, Box 1603, Clark Atlanta University, 223 James P. Brawley Drive, Atlanta, GA. 30314



Abstract
Project Excell was an intensive outpatient treatment program initiated in Fulton county, GA.  Individuals engaged in this project were 60 homeless males suffering from co-occurring substance abuse and mental health disorders.  Clients were provided with services to match their physical, mental health, substance abuse treatment, job skills training needs.  An evaluation of the data collected via the Family Assessment Questionnaire (FAQ), Addiction Severity Index (ASI), Multipurpose Information Consumer Profile (MICP), and protocol of the Georgia Performance Reporting Act (GPRA) revealed significant improvements in various bio-psycho-social measures over a period of 6-months.  Improvements were found in employment status, recidivism, use of emergency room services for mental and physical health purposes. Thus, Project Excell’s Best Practices Model of matching all the client needs with services and the Stages of Change substance abuse treatment model reaped positive client outcomes.

Keywords: outpatient treatment, homeless, males, co-occurring disorders, evaluation.


Introduction
“Addiction treatment providers are continually challenged to improve services. Often, these challenges occur in a fiscal growth environment that is not only flat, but in most instances, declining. Over the past decade, there has been an increased awareness of the common presentation of persons with co-occurring psychiatric disorders in routine addiction settings. National and state initiatives have been significant, and have stimulated considerable interest in providing better services for co-occurring disorders. Although clearly interested in doing so, addiction treatment providers have lacked pragmatic guidance on how to improve existing services (The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index, 2006, p.4; http://www.adp.ca.gov/COD/pdf/ddcat_toolkit.pdf ).” A state survey report (Department of Human Services, 2008) asserted that individuals with co-occurring disorders are 20 times more likely to be hospitalized and use emergency services, show increased rates of homelessness, are vulnerable to housing instability, are susceptible to premature death, and are more likely to be incarcerated.  Project Excell was a response to this need for services for the homeless males with co-occurring disorders in Fulton county, GA.

Project Excell
The greater metropolitan area of Atlanta, Georgia has a population of 3.5 million individuals. Included in this population are richly diverse communities of color, ethnicity and class distinction.  About 20 percent of the area’s population has no health insurance.  One-half of those with insurance are African- American and 39 percent are between the ages of 25 to 44 years old.

Overall, 54% of Fulton County’s residents are African American, 41% are European American, and three 3% are Hispanic. According to US Census Data, Georgia ranks 13th in the nation with people below the national poverty level.  Georgia has a rate of 12.3 % as compared with the rate of 20 % for Fulton County residents.  According to the Atlanta Regional Commission, 34% of individuals who are homeless are also mentally ill, often with a co-occurring diagnosis.

Project Excell was a program initiated by Fulton County Department of Behavioral Health and Developmental Disorders (Oct.2008 – Dec. 2009). Individuals targeted for this project were those who experiencing co-occurring substance abuse and mental health disorders. These individuals were homeless and found residence with Fulton County, Georgia.  Project Excell engaged 60 homeless males suffering form co-occurring substance abuse and mental health disorders in intensive outpatient treatment.      
Best Practices Model

DDCAT identifies the service types provided to individuals with co-occurring disorders, and that they range from consultation, collaborative, to integrative.  The consultation end involves an occasional communication between the client treatment providers about the clients’ status and progress, whereas the integrative end involves the provision of substance abuse and mental health services in the same treatment plan.   Project Excell was based on the ‘best practices model’ and provided integrative services to their homeless clients with co-occurring disorders.

Another set of ‘best practices’ identified by the Substance Abuse and Mental Health Administration report (SAMHSA, 2003) was the staff training and utilization of motivational interviewing.  Motivational interviewing is a counseling style designed to help clients change their behavior by exploring and resolving their ambivalence about that behavior. Project Excell staff were trained in this technique.  Futhermore, process and outcome evaluations of Project Excell were conducted to evaluate client outcomes after each quarter over a one year period. 

Trans-theoretical Stages of Change Model

The Trans-theoretical Model of Change, has been the basis for developing effective interventions to promote changes in health behaviors. The Transtheoretical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997) is a model of behavior change which integrates constructs from other theories. The central organizing construct of the model is the ‘stages of change’ which encompasses the model of intentional change. Intentional change involves decision making by the individual and also involves emotions, cognitions, and behavior. External influences such as social and physical environments are also considered as impacting through the individual. The model involves a reliance on self-report. 

The trans-theoretical model construes change as a process involving progress through a series of five stages. The five stages are: Pre-contemplation, contemplation, preparation, action, maintenance. Pre-contemplation is the stage in which people are not intending to take action in the near future (6-months) because they are uninformed about the consequences of their behavior. Contemplation is the stage in which people are intending to change in the next 6-months. This is considered the procrastination stage.  Preparation is the stage in which people are intending to take action in the immediate future (in a month). Action is the stage in which people have made specific overt modifications in their life-styles within the past 6-months. The action stage is also the stage where vigilance against relapse is critical. Maintenance is the stage in which people are working to prevent relapse.  They are more confident that they can continue their change.  The Trans-theoretical Model can provide sensitive measures of progress and a set of outcome measures that are sensitive to a full range of cognitive, emotional, and behavioral changes and recognize and reinforce smaller steps than traditional action-oriented approaches.  Project Excell recognized that addiction treatment was not an all or none event, but a process which ebbed and flowed.  The clinicians assessed the clients’ stage of change and matched reinforcements and services to help the client move to the next level. 

Treatment programs for homeless consumers
An overview of homeless programs and detoxification facilities indicates that the programs and facilities have different goals and provide varied services. For example, programs have been geared toward treating drunk drivers, homeless clients with mental health problems, homeless clients with poly-drug abuse, homeless clients with a history of alcohol abuse, or substance abuse treatment centers for any homeless clients. Services vary from basic detoxification, to detoxification followed by a short-term treatment program, or short-term treatment program followed by a long-term treatment program, residential programs or non-residential programs (Talpade, 2003)

Leon, Sacks, Staines, McKendrick (2000) identified successful outcomes in terms of longterm stability of a therapeutic community treatment program for treating mentally ill chemical abusing homeless clients. Dickey (2000) estimated that 25% of the homeless population was mentally ill and that this population was qualitatively different from those who are only mentally ill.  Similarly, Kertesz et al. (2007) report findings of the national survey data, among homeless persons with a drug abuse history (58% of the total), 17% reported receipt of inpatient or residential treatment within the past year, projecting up to 1/2 million inpatient treatment episodes per year among homeless persons. Only a minority of participants achieved favorable employment or housing outcomes at one year.  The authors acknowledge that this treatment, although resource intensive, was insufficient to help many participants with both homelessness and high levels of psychological distress. Thus, the need to acknowledge multiple needs and match the consumer profile with treatment services is imminent.

Dickey (2000) summarized the need for such disparity research by the following words:
Doing research, of course, is not the same as improving the lives of those who are mentally ill and homeless.  However, as society becomes more attentive to evidence-based policy, the link between research and public support for policy initiatives grows stronger.  Professionals and advocates can collaborate in a way that honors individual rights and contributes to the social good (p.8).

Project Excell was geared toward matching the client needs with services.  Thus, it was predicted that Project Excell would improve the bio-psycho-social status of the clients in the program, the homeless males with co-occurring disorders, over a period of 6-months. Specifically it was expected that: (1) Alcohol and Drug use reports would decline, (2) Housing status, education, employment, and income would improve, (3) Crime and criminal justice status would improve, (4) Mental and physical health outcomes would improve, (5) risky behaviors would decline, (6) Social connectedness would improve. 

Method
Design and Participants
Participants.  Consumers in Project Excell were all males, with 75% Black, 12% white, 2% Hispanic, and  11% reporting ‘other’ as their racial category.  The age range of these males is 19 to 67 years, with a median age of 44 years.  The majority (50%) range between the ages of 35-54 years.  Archival data reports the following incidence of the consumers with co-occurring disorders (66%, n=40) in the program.  Sixty-seven percent (n=41) had mental health needs, 100% (n=60) needed substance abuse treatment.  Additionally, 90% of the clients were not enrolled in any training, 38% who were the majority,  had 12 years of school, 76% were unemployed, 21% had been arrested,  41% reported poor to fair health; 15% had sought inpatient help for alcohol/drug problems and mental health needs; 10% had sought outpatient help for physical needs, 26% sought outpatient help for drug/alcohol abuse problems and mental health needs.  Fifteen percent of the clients sought emergency room (ER) treatment for physical problems, 10% for mental problems, and 2% went to the ER for alcohol/drug problems.  Twenty-six percent of the clients reported being depressed in the past 30 days, 21% of the clients reported being anxious in the past 30 days, 13% of the clients reported experiencing hallucinations in the past 30 days; 5% reported suicidal tendencies in the past 30 days.  Thus, the clients of Project Excell had significant substance abuse, mental health, physical health, and housing challenges. 

Materials
The assessment protocol of Project Excell included a Family Assessment Questionnaire (FAQ), Addiction Severity Index (ASI), Multipurpose Information Consumer Profile (MICP), record of the Georgia Performance Reporting Act (GPRA) data.

The FAQ was administered to all consumers at the Center for Behavioral Health and Addictive Diseases to assess why the consumers came to the center.  The ASI, is a self-report measure which taps into the mental health and biopsychosocial needs of the consumers.  This measure is based on the clear assumption that individuals entering treatment have a co-occurring psychiatric disorder. The MICP is a record of the consumers biopsychosocial and criminal history over one’s lifetime, whereas the GPRA is a record of the consumers’ biopsychosocial history over the past 6-months. The MICP tracks the participant’s biopsychosocial history, many which are not reflected in the GPRA.  For example, evidence of suicide attempts, spirituality, family support, family history of mental health and chemical dependence, and leisure activities are recorded and can be used by the counselor or case manager to facilitate treatment.

Procedure
Consumers of Project Excell came from the Fulton county homeless shelters, transitional houses, Mental health jail diversion services, and the Georgia Crisis Line.   After the FAQ was administered, consumers were provided with informed consent and their signature was acquired on a SAMHSA approved consent form.  Screening and assessment were conducted at intake, with the GPRA data collected at the same time.  A psychiatric evaluation, nursing (medical) evaluation, urine test results were assessed and documented.  The MICP and ASI were administered to the clients to determine current client needs and record the past biopsychosocial history. 

Counselors kept track of individual attendance for group therapy.  The clients had to attend 8-12 sessions, three hours per day for three days per week.  Consecutive attendance was encouraged, however, if the participant missed any session, they had to complete the 8-12 recommended sessions. If participants missed three sessions consecutively, their file was deemed closed and ineligible for services.

The program manager and six staff members provided treatment services to the participants.  This included three Licensed Professional Counselors, one licensed Addiction Professional Counselor, one M.S. in Human Services.  Additionally two psychiatrists, a nurse clinician evaluated the mental and physical health needs of the clients.  Medical needs of participants were met by service providers of Fulton county.

Services
 Clients in the Excell program were provided with intensive outpatient services with group counseling sessions held during the day at the Center for Health and Rehabilitation.  More intensive individual counseling was provided for those needing such counseling, and Treatment planning was provided to all clients.

Screening and Assessment was conducted at intake, with the GPRA data collected at the same time. The Family Assessment Questionnaire was administered to all clients at the Center for Health and Rehabilitation to assess why the client came to the center. The MICP and ASI were administered to the clients to determine current client needs and record the past biopsychosocial history. Aftercare services were provided to clients who did not have such services at the place of referral.  Sites with consistent follow up client services were identified for client placement.

Clients were provided with intensive outpatient day treatment, individual and group counseling and recovery support.  Cooccurring treatment and recovery support were provided to those who needed such support.  HIV/AIDS counseling was also provided.  Case management services provided to the clients included family services, employment coaching, services.  Medical services included alcohol/drug testing, HIV/AIDS services.  Aftercare services included continues care, relapse prevention, recovery coaching.  Educational services included substance abuse education and HIV AIDS education.  The recovery support services included peer coaching and drug free socials.  The cost per client was $722.

Results
Data from 60 homeless males with co-occurring/ substance abuse/mental health challenges were analyzed using the SPSS.  A follow-up of 49 clients was conducted and the intake and follow-up data were compared to evaluate if the predicted outcomes were obtained. The follow-up rate for Project Excell was 94.2% compared to 67.7% for other grantees.
Alcohol/Drug Use in the past 30 days: Intake Versus at 6-months after intake

Data of 49 clients at intake and after 6-months was compared.  Repeated measures MANOVA revealed significant decline over time on the measures of : Alcohol intake over the past 30 days, F (1,13)= 15.36, p = .002 Use of Illegal Drugs over the past 30 days, F (1,13)= 5.44, p = .036, Use of Alcohol and Drugs over the past 30 days, F (1,13)= 17.04, p = .001, use of Cocaine over the past 30 days; F (1,13)= 9.52, p = .009.  See Table 1 for descriptive statistics.

Table 1
  Alcohol and Drug Use over the past 30 days: Descriptive Statistics  
Interview
 
Used
Alcohol
Used Illegal
Drugs
Used Both Alcohol      and Drugs Used Cocaine
Intake
      Mean
      N
     SD
6-month
follow-up
     
Mean
     N
     SD
 
 
3.77
    57
8.47
 
 
1.00
    48
      3.35
 
 
5.44
    55
10.47
 
 
.75
   48
      2.56
 
 
14.55
    11
12.14
 
 
5.67
      3
             7.23
 
 
2.44
    55
6.97
 
 
  .31
   48
     2.02


Housing Status, Education, Employment, Income: Intake Versus at 6-months after intake


Nonparametric and parametric statistics were computed on the client reports.  Chi square analyses of client reports at intake and after 6-months on housing and employment status revealed non significant improvements.  Changes in housing status, with more clients in shelters, fewer on the streets and institutions,  more residing in own apartments, were reported.  Also, although non significant, more clients reported working part time after 6-months than at intake.  Repeated measures MANOVA did not reveal significant differences on the variables of Income and Education.
Crime and Criminal Justice Status: Intake Versus at 6-months after intake

Improvements in criminal status (no arrests, drug related arrests), number of days confined, number of crimes, number of arrests, parole status, were noted 6-months after intake.  Chi-square tests revealed significant differences/decline in drug related arrests, χ2 (1, 19) = 4.05, p = .044.  Although chi square analyses revealed non significant differences, there were positive changes in the number of clients awaiting trial and those who were on parole/probation.  Pairwise comparisons on the number of arrests, number of days confined, and the number of crimes revealed non significant differences. 

Mental and Physical Health Problems and Treatment: Intake Versus at 6-months after intake

Positive changes in perceived impact of alcohol/drugs on brain function were found, F (1, 31) = 4.26, p = .047.  Significant increases in stress, F (1, 31) = 24.24, p = .000; and emotions,  F (1, 31) = 40.53, p = .000; were evidenced after 6-months. 
Treatment for Alcohol/Drug related problems, Mental health, Physical health

Results indicate statistically significant reduction in reports of clients seeking Inpatient treatment for Mental problems,  ,  χ2 (1, N = 107) = 3.85, p = .050 (likelihood ratio); from 5% at intake to none after 6 –months, Emergency Room (ER) treatment for Physical problems, ,  χ2 (1, N = 107) = 3.85, p =.050 (likelihood ratio); from 10% at intake to 1% after 6 –months, ER treatment for Mental problems,  χ2 (1, N = 106) = 5.06, p =.022,  from 10% at intake to 1% after 6 –months. 
Sexual Behaviors : Intake Versus at 6-months after intake
    
Sexual behaviors were evaluated by responses to questions regarding the number of sexual contacts in the past 30 days whereas risky sexual behaviors were evaluated as responses to questions such as engaging in sex without using condoms, sex with a HIV positive partner, sex with a partner when high on alcohol/drugs.  Results indicated that  although pairwise comparisons and chi square analyses did not reveal statistically significant differences, risky sexual behaviors reduced after 6-months.

Social Connectedness:  Intake Versus at 6-months after Intake

Chi square tests and repeated measures ANOVA revealed non significant differences in social connectedness.  Social connectedness behaviors were defined by attendance of organizations supporting recovery, attendance of self help groups, religious groups,  interactions with family and friends, and the number of family members that clients could turn to when in trouble. Although non significant, clients reported having people such as clergy, family, friends, and sponsor to turn to when in need.
Age Group X Interview Type x Educational Attainment

A MANOVA conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of Age Group (Younger versus Older) and Interview type, revealed significant interactions between the Educational level as a function of Age and Interview type; F (1,42) = 4.79, p = .035.  Thus, educational level of older participants increased over time whereas the educational level of younger participants decreased over the 6 month period.  See Table 2 for descriptive statistics.

Table 2
 Education level as a function of Age and Interview type: Descriptive Statistics   
Interview Age group Educational Level Descriptives
Intake 18-44 years
 
 
45-65+ years
                   Mean
                        SD
                          N
                   Mean
                        SD
                          N
11.94
1.85
17
11.45
3.67
11
6 month follow up 18-44 years
 
 
45-65+ years
                   Mean
                        SD
                          N
                   Mean
                        SD
                          N
10.88
1.36
8
14.00
2.53
6



Employment Status X Interview Type x Stress level

A MANOVA conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of Employment Status and Interview type, revealed significant interactions between the Employment Status (fulltime versus part time)  as a function of Age and Interview type; F (1,39) = 6.91, p = .013.  Thus, stress level of part time participants decreased over time (from Mean = 2.93, SD = 1.16 to Mean = 2.33, SD = 1.75) whereas the stress level of full time participants increased (from Mean = 2.33, SD = 1.30 to Mean = 4.14, SD = 1.46) over the 6-month period.
Use of Inpatient Services for Mental Problems X Interview Type x Psychological Problems

A Kruskall-Wallis analyses conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of the use of Inpatient services for Mental problems and Interview type, revealed significant  effects  between the Use of Inpatient Services (yes versus no)  Interview type, and Depression, Stress, Anxiety, Suicide, and Psychotropic Medications.  Thus, the use of inpatient services for mental problems were significantly related to the experience of stress, χ2 (2, N = 48) = 6.15, p = .046, depression,  χ2 (3, N = 99) = 8.29, p = .040, anxiety, χ2 (3, N = 102) = 9.57, p = .023,  suicide, χ2 (3, N = 101) = 20.87, p = .000, and the use of psychotropic medications, χ2 (3, N = 102) = 16.67, p = .001. A comparison of the Mean Ranks (see Table 3)  revealed that reports of depression, suicide, and the use of psychotropic medications at intake, was a predictor for the use of inpatient treatment for mental problems.  Stress however was not a good predictor for the use of inpatient treatment for mental problems.
Use of Inpatient Services for Physical Problems X Interview Type x Psychological Problems

Table 3
 Use of Inpatient Services for Mental Problems X Interview Type x Psychological Problems  
Variables Interview Response N Mean Rank
Stress Intake Yes 8 30
  Intake No 27 21
  6-months No 14 31
Depression Intake Yes 8 72
  Intake No 45 48
  6-months No 46 50
64
Anxiety Intake Yes 8 65
  Intake No 46 46
  6-months No 46
2
53
85
Suicidal behavior Intake Yes 9 61
  Intake No 45 51
  6-months No 46
2
51
51
Psychotropic
Medications
Intake Yes 9 75
  Intake No 45 45
  6-months No 46
2

53

84



A Kruskall-Wallis analyses conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of the use of Inpatient services for Physical problems and Interview type, revealed significant  effects  between the Use of Inpatient Services (yes versus no)  Interview type, and number of violent acts in the past 30 days, χ2 (3, N = 103) = 12.15, p = .007. The Mean Ranks revealed that the number of violent acts in the past 30 days predicted the use of inpatient services for physical problems (see Table 4).

Table 4
 Use of Inpatient Services for Physical Problems X Interview Type X Psychological Problems  
Variables Interview Response N Mean Rank
Violent Acts Intake Yes 1 102
  Intake No 54 53
  6-months         
6-months
Yes
No
1
47
90
49
 


Use of Inpatient Services for Alcohol/Drug related Problems X Interview Type X Psychological Problems

A Kruskall-Wallis analyses conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of the use of Inpatient services for Alcohol/drug use problems and Interview type, revealed significant effects of the use of Inpatient Services (yes versus no)  Interview type, on stress, χ2 (3, N = 49) = 9.30, p = .026, and education level, χ2 (3, N = 107) = 11.06, p = .011.  A higher level of education and stress predicted the use of inpatient services for alcohol/drug problems (see Table 5).


Table 5  
Use of Inpatient Services for Alcohol/Drug related Problems X Interview Type X Psychological Problems  
Variables Interview Response N Mean Rank
Stress Intake Yes 5 28
  Intake No 30 22
  6-months         
6-months
Yes
No
3
11
46
26
Education Intake Yes 8 83
  Intake No 51 48
  6-months         
6-months
Yes
No
8
40
65
54



Use of Emergency Room Services for Mental Problems X Interview Type X Psychological Problems
A Kruskall-Wallis analyses conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of the use of ER services for Mental problems and Interview type, revealed significant  effects  between the Use of ER Services (yes versus no)  Interview type, and experiencing Stress, χ2 (2, N = 48) = 8.26, p = .016; Hallucinations, χ2 (2, N = 99) = 8.64, p = .013; Violent acts, χ2 (2, N = 102) = 6.48, p = .039; Suicide, χ2 (2, N = 101) = 31.98, p = .000;  and Psychotropic medications,  χ2 (2, N = 102) = 14.48, p = .001; in the past 30 days.  Thus, the presence of stress, hallucinations, violent acts, suicide, and use of psychotropic medications at intake predicted the use of ER services for mental problems.  See Table 6 for Mean Ranks.

Table 6
Use of ER Services for Mental Problems X Interview Type X Psychological Problems  
Variables Interview Response N Mean Rank
Stress Intake Yes 6 33
  Intake No 28 20
  6-months No 14 30
Hallucinations Intake Yes 5 71
  Intake No 46 47
  6-months No 48 50
Violent Acts Intake Yes 6 70
  Intake No 48 51
  6-months No 48 50
Suicidal behavior Intake Yes 6 67
  Intake No 47 50
  6-months No 48 50
Psychotropic
Medications
Intake Yes 6 83
  Intake No 48 46
  6-months No 48 53


Use of Emergency Room Services for Alcohol/Drug use Problems X Interview Type X Psychological Problems
A Kruskall-Wallis analyses conducted on target psychological variables such as reports of stress, educational level, depression, anxiety, hallucinations, brain function, violent behaviors, health status, and psychotropic medications as a function of the use of ER services for Physical problems and Interview type, revealed significant effects between the use of ER Services (yes versus no)  Interview type, and experience of Anxiety, , χ2 (2, N = 102) = 6.22, p = .045 ;  and Violent acts, , χ2 (2, N = 103) = 7.58, p = .023.  Thus, anxiety and violent acts at intake predicted the use of ER services for alcohol and drug problems.  See Table 7.

Table 7  
Use of ER Services for Alcohol/Drug use Problems X Interview Type X Psychological Problems  
Variables Interview Response N Mean Rank
Anxiety Intake Yes 1 100
  Intake No 53 48
  6-months          
 
No
 
48
 
54
Violent Acts Intake Yes 1 102
  Intake No 54 53
  6-months No 48 50

 

Discussion
Project Excell resulted in a substantial number of changes in the status of the clients.  Project Excell improved the biopsychosocialstatus of the clients in the program. These findings are corroborated by reflections of the staff in direct contact with the clients of Project Excell who agreed that the program made a positive impact on the clients related to their addiction, mental health, employability, recovery/rehabilitation.  Similar results have been evidenced by other treatment programs for clients with co-occurring disorders where receipt of professional service delivered superior outcomes (Gonzales & Rosenheck, 2002). They also indicated that short –term improvements were found across the board, and long-term improvements were deemed to persist with ongoing support systems. 

Although improvements were not evidenced on all the measures, there were substantial changes toward the positive in client status over the short period of treatment and follow up time.  Specifically, more clients were working part-time; these findings are positive considering the current employment conditions. This may explain the results related to stress where full time workers were more stressed (may have fear of losing their jobs) in comparison to part-time workers (who may just be thankful for finding a job). Drug-related arrests declined significantly over the period of 6-months (from n = 6 to n = 0).  The use of ER services for Mental and Physical health purposes, and inpatient mental health services declined over time. More clients sought ER services at intake for varied problems and is attributed to the lack of insurance, lack of health care, lack of resources.  Use of ER services reduced over time probably indicating an increase in support systems and coping strategies. Unlike what was found at intake, poor mental health status was associated with attendance of recovery groups, suggesting that the clients had probably learnt coping skills to aid their recovery.

Despite these positive outcomes, it is acknowledged that some of the findings were not as positive.  That is more clients were housed in shelters after 6-months or were theoretically, homeless.  These findings are attributed to the resources available at the shelters; food, shelter, treatment, vocational rehabilitation.  In the absence of any financial resources, the shelters were thus the best available option.  Also, as a clinician pointed out, shelters provide a sense of community instead of an apartment where they would feel isolated. Reports of stress and emotions increased with time.  It is postulated that the encounter with outside environmental stressors and the lack of the controlled supportive environment may have caused these outcomes. 

Age was negatively correlated mental health problems and with sexual activity.  It is postulated that because of this relationship, older clients were more likely to keep up their psychotropic medication regimen, rather than younger clients who, according to the counselors, discontinued their medications due to a negative impact on sexual activity.  This relationship may also explain why older clients continued to increase their educational level in contrast to the younger clients.  This relationship between lack of education and homelessness has been corroborated by other researchers (Calsyn & Roades, 1994).  Thus, as some of these findings indicate, this program had better outcomes for the older clients.

Future implications and improvements for programs such as this are derived from staff reflections. Staff made recommendations to enhance treatment outcomes.  They were, incorporating  a pretreatment component to educate clients about expected outcomes and benefit of program completion; transportation and meals continued for a longer period of time 6-12 months after discharge from program; healthcare on a sliding fee ;  case management continued from nine months to one year based on the needs of the client, because clients with co-occurring disorders are the most difficult to rehabilitate and need more intensive case management and support.  For clients with mental health issues, clients needed semi independent housing with ongoing support.  Relapse is a part of recovery (85%) therefore the staff argued, enough time was important to rehabilitate the client. Also, motivation increased when the clients had fewer needs. 

Staff also ascertained that one element ubiquitous for recovery, in addition to support systems available after leaving the program, was motivation of the client.  To provide both, it was recommended that the follow up be continued in the community, with affordable housing, which is supervised by mental health professionals who could monitor and control negative client outcomes. Providing such a therapeutic community has delivered significantly positive outcomes especially among those with mental health issues (Leon et al., 2000).   Improved outcomes for those with stable housing as a part of the treatment have been corroborated by others (Kertesz, 2007).

Thus, future interventions geared toward the homeless will benefit from the treatment model used by Project Excell and will reap long term benefits if the staff recommendations of extended treatment, follow-up, and support services are initiated.  In summary, the brief intervention Project Excell improved client outcomes on several biopsychosocial measures and provided hope and healing for the homeless males in Fulton county, Georgia. 


References
The Dual Diagnosis Capability in Addiction Treatment Index . (2006, December). DDCAT.      Retrieved from www.adp.ca.gov/COD/pdf/ddcat. 

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