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Co-Occurring Disorders and Homelessness

Integrated Screening and Assessment for Co-Occurring Disorders for Individuals Experiencing Homelessness

While integrated care has been cited as important to the recovery of individuals with co-occurring mental and substance use disorders who are experiencing homelessness, few have the ability to access to it. People experiencing homelessness may be isolated or have little or no access to health and behavioral health services. Thus, individuals experiencing homelessness with co-occurring disorders may be undiagnosed and untreated. This can lead to continued homelessness and further deterioration in physical, social, and economic functioning.

One way to improve access to integrated care for individuals experiencing homelessness is to implement integrated screening and assessment throughout the homeless system of care. Integrated screening determines the likelihood that an individual experiencing homelessness has co-occurring disorders or that co-occurring disorders may be influencing his or her presenting signs, symptoms, or behaviors.

What is integrated screening?

The purpose of integrated screening is not to establish the presence or specific type of such a disorder, but to establish the need for an in-depth assessment. Screening is a formal process that typically is brief and occurs soon after the client presents for services.

In the "No Wrong Door" approach every point of entry into the system is seen as an opportunity for outreach, education, and connection to needed services. This approach is used in health, behavioral health, and homeless systems to ensure that an individual experiencing homelessness has access to the full range of services the individual needs. While not all settings can or should provide comprehensive co-occurring disorder services, they afford important opportunities for engagement can serve as gateways to integrated systems of care.

Effective Screening Requires Building Trust

Practitioners working with persons experiencing homelessness must balance the importance of screening with a sensitivity for the individual's past experiences. Effective screening requires establishing trust. Screenings may occur in many locations such as:

  • Shelters
  • Soup kitchens
  • On the street
  • In medical or dental programs

Screening is most effective when combined with outreach and engagement to dissolve reluctance to follow up on referrals or seek treatment, if necessary. Caring for individuals who are homeless is as much about building relationships as it is about clinical expertise, and nonjudgmental, supportive interactions are essential to engaging homeless individuals in a therapeutic alliance. Offering incentives such as lunch, coffee, clothing, bus tokens, and personal care products can promote engagement. Once engaged, providing access to supportive housing can have a powerful effect on outcomes for homeless persons with co-occurring disorders.


After screening, assessment is the next step in connecting persons experiencing homelessness to the services they need. Assessment is an ongoing process of collecting and organizing information, making immediate decisions, and formulating appropriate treatment and referral plans. Information collection for assessments includes:

  • Direct client interviews
  • Collateral data
  • Client observations
  • Review of available documented history

Assessing homeless individuals presents special challenges for practitioners in terms of collecting and interpreting information that serves both the immediate and long-term needs of each client.

Characteristics of assessment that are specific to the unique needs of individuals with co-occurring disorders who are experiencing homelessness include:

  • Assessment is Continuous: A part of every client contact includes collecting and interpreting information. A comprehensive picture can take many weeks or months to compile.
  • Assessment Responds to Needs: Because homeless people with co-occurring disorders have such a diverse range of problems that can place basic survival in jeopardy, assessments can be structured to follow a hierarchy of need. After crisis situations have been stabilized and the most immediate basic support needs have been attended to, practitioners then can focus on issues related to social and psychological history.

Learn more about screening and assessment.

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