Hoarding Response Team (HRT)

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1.0 SummaryHRT-logo
The Town of Arlington launched a newly formed Hoarding Response Team (hereinafter ‘HRT’) in the summer of 2011. Representatives of the Arlington Health Department and the Arlington Police Department began meeting formally to discuss the formation and structure of such a team in May 2011. Hoarding cases were becoming increasingly more common in Town, and were most often extremely time-consuming happenstances for all parties involved. In the two years prior, the Town had seen a marked increase in newly reported cases, nearly an estimated 30% rise over years past, which was speculatively attributed to the awareness created by national television programs spotlighting the condition known as hoarding. While hoarding was not a new issue faced by Town staff, an aging residency and the increasing number of reports necessitated a more systematic and formal approach to effectively address the need; formerly, the Town approached the issue primarily reactively, and in a seemingly disjointed manner lacking the required efficiency to achieve consistent results. The Hoarding Response Team (HRT) is comprised of members from various Departments throughout Town and is currently handling many ongoing cases, and still receives direct referrals on a regular basis, while trying to further expand its resource and knowledge base as well as best response practices. In addition to the persons specifically named to the HRT, all Police and Fire Department personnel received specialized hoarding training during the initial phase of the project. The HRT also works with various outside agencies and has developed and maintained a network of contacts and organizations to meet the needs of varying situations, as detailed in the resources section.

2.0 Background
In May 2011, the formal discussion of a coordinated hoarding response was solidified when the Arlington Police Department, in partnership with the Arlington Health and Human Services Department, sought out and received grant funding from the Massachusetts Department of Mental Health. The grant was the first ever awarded to a police department in the Commonwealth for supporting such a cause. Rebecca Wolfe, the Police Department’s Mental Health Clinician, would serve as a single point of contact for Town residents and Departments. Previously, the Health Department served as the point of contact, potentially dissuading those with concerns from making a referral due to fear of enforcement action.

The next step would involve meeting with an expert in the field to discuss the approaches and strategies available to a task-force style HRT. Arlington HRT members worked with Christiana Bratiotis, a post-doctoral researcher and Director of the Boston University School of Social Work’s Hoarding Research Project, to develop an approach that would best meet the current needs and resources in the community. In addition, Dr. Bratiotis would educate HRT members about the current research in the field and provide recommendations for appropriate educational materials and practical tools. With this guidance, the HRT invested in multiple publications of Drs. Gail Steketee and Randy Frost, including “Compulsive Hoarding and Acquiring: Workbook” and “Compulsive Hoarding and Acquiring: Therapist’s Guide.” Furthermore, HRT members were educated on the application of various practical tools, such as the “The Saving Inventory-Revised” (Frost, Steketee, & Grisham, 2004), “The Clutter Image Rating” (Frost, Steketee, Tolin, & Renaud, 2006) and “Activities of Daily Living for Hoarding” (ADL-H, Frost & Steketee, unpublished).

Shortly thereafter, the HRT worked with Carley Lubarsky, a local social worker, to provide formal hoarding response education and training on various aspects of hoarding, including the field use of some of the practical tools listed above, to all Police and Fire department personnel. These trainings increased awareness among first responders, and similarly increased the understanding of and degree of sensitivity for persons with this particular mental illness; other valuable lessons included encouraging first responders to gather photographic and documentary evidence where possible and necessary, ensuring all reports were written with a high-level of detail in the event the information may need to be used in the future to secure an administrative inspection/search warrant, and also how to classify hoarding situations versus squalid living situations. Police Officer Michael Foley is currently assigned to the HRT and assists with emergency response, continued training of officers, and equipping cruisers with the tools necessary for assessing and reporting unsanitary living conditions.

After the completion of the training sessions, the Town and local media made press releases regarding the grant and subsequent formation of the HRT. This publicity would serve to increase awareness and notify the public of the HRT and inform them of the single point of contact for intake and referral. And, indeed, this would result in yet a further marked increase of calls from concerned family members and neighbors who did not previously know where to turn, or what steps they could take.

3.0 Program Description
Currently, the HRT employs a hazard reduction model for handling hoarding cases. With limited resources, reducing or eliminating personal and household life and safety hazards for both the occupant and first responders is paramount; while hoarding cases present in a myriad of ways, the ‘carrot and stick’ approach is oft applicable to accomplish this end. While the task force approach to handling hoarding is not necessarily an innovative concept, the innovation is found in the specific model and approach taken when handling hoarding cases. The HRT, in practice, is both rigid and flexible.

Identifying and tracking both confirmed and suspected hoarding cases is the first step in preventing harm. Prior knowledge of hoarded conditions can greatly affect a Firefighter’s rescue and response strategy and may contribute to a safer, more efficient approach for all parties involved. Here, prevention is of paramount importance in preventing serious injury and the potential loss of life. Referrals may come directly from a concerned family member, neighbor, serviceman, health care provider or other visitor who has witnessed the conditions inside a home, or has reason to believe such conditions exist in a home. Similarly, hoarding cases may also be revealed indirectly when investigating other nuisance complaints, especially in multi-family dwellings, such as odors or pest control problems. Furthermore, and as is often the case, hoarding cases are often discovered by first responders during emergency response events, frequently related to or resultant from the hoarded conditions. Hoarding cases can even be identified proactively by Police Officers taking notice of hoarded vehicles.

If and when first responders identify hoarding cases, they are trained to gather information and contact the Mental Health Clinician and Health Department while on site. Emergency situations often give rise to an environment conducive to a hoarder granting access to Health Department staff, so every effort is made to respond at the time of the event. An increased number of cases are first-responder driven now that responders have been trained and have a formalized process for reporting and follow-up. Co-response by Health Department staff and the Mental Health Clinician at the time of an emergency call has proved invaluable in expediting the process of hazard reduction; the acute and serious nature of emergency calls, as well as the daunting presence of public safety officials lends greatly to decreased resistance by the occupant. When access is achieved expeditiously, more time and resources can be dedicated to coordinated follow-up.

In non-emergency situations, the Mental Health Clinician conducts preliminary outreach via home visit or telephone in hopes of establishing rapport at the outset of the process, i.e. the ‘carrot.’ Thus far, hoarders have been more amenable to establishing initial communication with a clinical responder than that of a code enforcer. This provides an opportunity to describe to the hoarder the code enforcement process, the available resources, and the potential options moving forward; however, this outreach is seldom solely enough to motivate a hoarder to take the steps necessary to reduce hazards inside the home, though at times is has proved effectual.

If the hoarder has not taken any action, the clinician attempts to schedule an inspection for code enforcement, typically only a short period of time after initial contact. If met with resistance, the Health Department will send a formal letter requesting inspection via certified mail, followed by a home visit by both Health Department staff and the clinician. If for some reason access is not granted at this point, it may be necessary to threaten obtaining an administrative search warrant, and ultimately obtaining one if necessary, though most often it can be explained such that it is clearly better to avoid court involvement. After an inspection is conducted, Health Department staff immediately begin drafting an order to correct violations of the 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation (State Sanitary Code, Chapter II)- the ‘stick.’ The order is often hand delivered so it can be explained in person, ensuring the expectations and timelines are understood. All inspections and home visits are conducted in the presence of a police officer for the safety of all involved parties, to give the interactions increased official value and perceived legitimacy while reducing resistance, and so the Officer can put all first responders on notice of the conditions based on first-hang knowledge. Likewise, a Council on Aging social worker will be present for all interactions involving seniors to provide support and referrals for outside services.

4.0 Results & Best Practices
To achieve consistent and desirable results, the HRT employs the same strategy with all cases, albeit hoarding cases, or cases of squalid living conditions. Though comprised of many members, the most efficient deployment of the HRT is by small number. Department heads are typically only involved in big-picture or long term procedural, planning, and funding decisions. For day-to-day operations, the HRT is comprised of two Health Department inspectors, the Mental Health Clinician, and the designated Police Officer. With this approach, all four members are involved with every case to ensure there are no gaps in service or follow-up, and to ensure no one member is over-burdened, as hoarding cases can frequently lead to ‘burn-out.’ Each case is actively monitored by the small group by an email thread with the address referenced in the subject line for ease of tracking. With this approach, the goal of hazard reduction is more quickly attained because each member has the same goal, with clearly delineated roles; outside services are sought by referral and the occupant is always a part of that decision making and follow-up process to ensure they retain control. This also allows those providing outside services to follow their own objectives without potentially conflicting with those of the HRT. With too many members or member agencies, any coordinated hoarding group can run the risk of being encumbered by varying and differing agendas which can render the process less efficient and less clear.

Under certain circumstances, Health Department staff need also be prepared to perform condemnations of dwellings. When the conditions of the home warrant condemnation, Town Counsel should always be consulted to ensure procedural guidelines are met, and the dwelling should always be placarded as such to notify the public. Again, the designated Police Officer is always present when performing a condemnation to explain the rules of access and/or trespass, and to reduce the potential for conflict. Condemnation may also be appropriate to finally effect compliance when all other manners of enforcement have failed, as displacement can be the most acute ‘wake-up’ call to a hoarder.

To date, the HRT has had many success stories, brief anecdotes of which will follow. In order to explore different options for services, the HRT always spends the time to establish a personal relationship with the hoarder so that all stakeholders are identified, which can lead to different avenues of service. For example, the HRT recently worked with the Shriners to provide services for a member at risk of being displaced from the home. Here, a completely volunteer workforce was used to provide all clean out and repair services, as well as support for the occupant. Similarly, the HRT has also recently worked with a church group to provide support, relocation assistance and maintenance services for one of its displaced members. Yet another case was brought to conclusion by way of TLC’s Hoarding: Buried Alive television program, which was further bolstered by recruiting a great deal of neighborhood volunteerism to assist with bringing the property and home back into compliance. Also of note is an active case in which a veteran in need was referred for services through both senior services and the Veteran’s Administration. Of course, in all instances, it took commitment from the HRT to persuade the hoarder towards accepting help and outside services. Though, there have been situations that have not gone as smoothly including one long-term case, which had not met resolution over many years. In this instance, the newly minted HRT was able to successfully petition the Superior Court with a proposed order for mandated family intervention and ongoing follow-up by the property management company; this particular case was also referred to a research program at a local university.

The formation of a formal and structured HRT has allowed the Town to reach an acceptable resolution in more cases, and in a more expedited fashion than in the past. Developing procedures has helped to streamline the entire process, and ensuring members are both enthusiastic and properly trained has helped with exploring and implementing creative avenues for clean-up and follow-up services.

5.0 Resources & Links
The strength of any HRT seemingly lies in the contacts made with the surrounding community. In the first year of operation, the HRT has grown more robust due to the ties developed with many people able to provide related services, including those in some of the sectors listed below. The HRT has reached out to develop these ties beforehand, in hopes of streamlining the process when services are needed, and already having plan for their delivery.

· Senior and Protective Services: Minuteman Senior Services
· Local dumpster and disposal services provided at a discounted rate to those affected by municipal enforcement
· Local handymen, contractors and tradesmen who self-identify as hoarding friendly and are willing to discount rates for those with inability to pay
· Clean-up contractors who self-identify as hoarding friendly, and are willing to provide time-sensitive consults, estimates and removal services
· Professional organizers and declutterers who can provide ongoing in-home services
· Producers at national television programs for case referral as appropriate
· Local shelters, housing agencies and transitional assistance agencies when occupants are displaced
· Local help groups and organizations, such as clutterers anonymous
· Local weatherization and home improvement loan programs for those who qualify
· Veterans’ service organizations, church groups, community service organizations

MassHousing Hoarding Resources
Research paper outlining Hoarding Rating Scale – Interview

6.0 Goals
In the years to come, the HRT looks to continue providing consistent services to all persons with unsanitary living conditions inside their homes to ensure access to safe and sanitary housing. But, with hopes of increasing the level of service, the following items will be explored:

· Conduct outreach and develop a volunteer database of persons in the community with an interest or expertise relative to the field, or those persons wanting or needing to perform community service that can reduce the burden of chores facing a hoarder
· Fundraising efforts, which can ultimately subsidize organizing services, disposal services, cleanout services, treatment groups etc.
· Establish strong working contacts with local mental health professionals for referral. Currently, with limited resources, the HRT is unable to provide treatment for the condition, which may be necessary to prevent relapse
· GIS mapping of homes with unsanitary living conditions; more accessible information for first responders
· Calculating measured statistics regarding the incidence and prevalence of cases, units of service, expenditure of resources etc.
· Continue education services for the community at large to identify, assist, and knowledge of the reporting process for suspected hoarders
· Provide post-compliance inspections and to assist hoarders in continued upkeep of their premises
· Continue to serve as a resource and model for other communities interested in developing Hoarding Response Teams