Abstract: More than 500,000 people experience homelessness on any given night in the United States (U.S. Department of Housing and Urban Development, 2017). Even with the large need for services to support occupational engagement, health, and well-being, the National Coalition for the Homeless (2009) reported that the majority of homeless individuals have access to few supportive services. Individuals experiencing homelessness often do not have access to housing, health-related, or transportation resources, and are not provided education for health maintenance, skills attainment, or home management. Often, underserved populations are not covered by traditional medical or educational services, yet they still have occupational needs. This article outlines the theoretical foundation for occupational therapy treatment for homeless individuals as well as treatment options for occupational therapy practitioners working with this population. LEARNING OBJECTIVES After reading this article, you should be able to: 1. Identify barriers preventing full occupational engagement among various populations experiencing homelessness 2. Discuss the role of occupational therapy within the homeless population 3. Identify the differences between community-based and community-built services 4. Identify the occupational needs of various subgroups in the homeless population INTRODUCTION More than 500,000 people experience homelessness on any given night in the United States (U.S. Department of Housing and Urban Development [HUD], 2017). Although there is no definitive cause of homelessness, the National Coalition for the Homeless (2009) reported that substance abuse; mental illness; domestic violence; and recent economic factors, such as decreases in public assistance programs and loss of jobs, are the most prevalent causes of homelessness. Homelessness has been identified as an issue within the United States for more than 8 decades, but the composition of the homeless population has changed dramatically in the past 40 years. In the 1950s to 1970s, the overwhelming majority of those who were homeless were single men (Burt et al., 2001). During the 1980s, more families were experiencing homelessness, and currently more than a third (35% to 37%) of the homeless population are members of homeless families (National Alliance to End Homelessness, 2018). This change in the homeless population created the need for new services and supports. In 2017, approximately 65% of the total homeless population was living in emergency shelters or transitional housing programs, and more than 184,000 were homeless individuals in families with children (HUD, 2017). Nearly 30% of the total sheltered homeless population is individuals in homeless families (HUD, 2017). Homeless families typically consist of a single mother younger than 30 years of age and with two or three children younger than 5 years of age (Bassuk Center on Homeless and Vulnerable Children & Youth, 2015). Homeless mothers experience higher levels of mental health issues, poor physical health, increased stress, loss of social supports, and deterioration of parental roles than housed low-income mothers (Helfrich et al., 2006; Schultz-Krohn et al., 2006). Even with the large need for services to support occupational engagement, health, and well-being, the National Coalition for the Homeless (2009) reported that the majority of homeless individuals has access to few supportive services. Individuals experiencing homelessness often do not have access to housing, health-related, or transportation resources and are not provided with education for health maintenance, skills attainment, or home management. Although many organizations exist within the community to provide health care and supportive services to people without housing, the lack of funding for these services results in strict inclusion criteria, long wait times, and stringent availability (National Alliance to End Homelessness, 2017). Other barriers to accessing services for individuals experiencing homelessness include lack of transportation to attend appointments, job interviews, or educational classes outside of their immediate area; poor literacy skills, resulting in the inability to complete necessary paperwork; lack of material resources WWW.AOTA.ORG CE-1 ARTICLE CODE CEA0618 CE-2 JUNE 2018 ARTICLE CODE CEA0618 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit. (e.g., telephone access); and concern about stigma from staff at support organizations (National Alliance to End Homelessness, 2017; Roy et al., 2017). Research findings have indicated that individuals experiencing homelessness are provided with limited opportunities to engage in meaningful occupations and therefore have decreased health outcomes, social interactions, and well-being (Glass et al., 2006). The element of personal choice is essential to deriving meaning from occupations, yet the institutional nature of the homeless shelter environment requires individuals seeking services to abide by strict curfews, mealtime schedules, and mandatory check-ins, resulting in few opportunities to make choices about occupational participation (Glass et al., 2006). Additionally, one study attributed the high prevalence of substance abuse within the homeless population to the minimal opportunities available for occupational engagement (Bradley et al., 2011). Similarly, homeless shelters do not provide opportunities for functional skill development (Illman et al., 2013). Based on the current literature available, it is evident that within the homeless population many barriers exist that prevent full engagement in meaningful occupations, therefore requiring occupation-based intervention services. THEORETICAL FOUNDATION The model of occupational justice was described by Townsend and Wilcock (2004) as a right of all individuals to participate in meaningful everyday occupations. The concept of occupational justice was built on a foundation of client-centered services, engagement in occupations as health promoting, and social justice. Specific elements of occupational justice include the concepts of enabling fairness and equal opportunity, removing discriminatory practices that are based on age or other factors, a clear commitment to universal design, and providing a contextual position that enables everyone to individually flourish as a member of a community. Marginalized populations seldom have opportunities to engage in meaningful occupations, and this is where occupational therapy services can diminish the occupational injustices by facilitating occupational participation (Townsend & Whiteford, 2005; VanLeit et al., 2006). Although occupational justice is often compared to social justice, it is considered a distinct entity (Stadnyk et al., 2010). Where social justice uses the lens of social relationships and citizenry, occupational justice focuses on engaging and participating in occupations to support health and well-being. When occupational engagement is diminished or compromised, occupational injustices are seen (Durocher et al., 2014). Durocher and colleagues (2014) outlined five distinct forms of occupational injustice that can serve as a guide to provide occupational therapy services to underserved populations and communities. Occupational apartheid is the form of occupational injustice encountered when specific groups of people are restricted from occupational pursuits because of personal characteristics. Societies and communities that prohibit occupational participation because of race, religion, and/or sexual orientation are examples of occupational apartheid. Occupational imbalance refers to excessive engagement in one occupation or group of occupations to the exclusion of other occupations. This imbalance can compromise health, such as when parents need to work two to three jobs to support the family. Occupational alienation is when individuals or populations are not able to engage in meaningful activities and instead engage in tasks whose requirements do not reflect their full capabilities. An example of occupational alienation could be when a woman living on the streets rummages through garbage cans to find plastic bottles to recycle for cash. Occupational deprivation is a common form of occupational injustice where illness or disability prohibits engagement in meaningful occupations. An example could be when a musician with severe arthritis is no longer able to play the piano. Occupational marginalization is the injustice seen when everyday options or choices are not available to every member of the society or community. An example could be persistent gender roles that restrict an individual’s options. Occupational therapy services are continuing to evolve to meet the occupational needs of an ever-expanding number of client groups. The American Occupational Therapy Association’s (AOTA’s) Vision 2025 calls for the profession to “maximize health, well-being, and quality of life for all people, populations, and communities” (AOTA, 2017, p. 7103420010p1). To help achieve this vision, practitioners can identify not only the occupational needs of current groups served, but also the needs of underserved people, populations, and communities. Community Built, Not Community Based When attempting to address the occupational needs of new and underserved populations and communities, a community-built model offers guidance and structure. Although many occupational therapy services are provided within a community-based setting, there is a distinct difference between a community-based and a community-built model of service delivery (Schultz-Krohn, 2012). In a community-based model, the occupational therapist determines what services will be provided and the frequency of services. Although the services are physically provided within a community setting, presumably close to the client’s living situation, the control and focus of the services p