Hoarding BestPracticeGuide

Hoarding: Best Practices Guide
TABLE OF CONTENTS
Sections: Page:
❶ INTRODUCTION ......................................................................................…... 2
❷ WHAT IS HOARDING AND HOW DOES IT AFFECT A COMMUNITY …………………………..….. 3-5
❸ DECISION TREE ……………………………………………………………………………………………. 6
❹ EARLY INTERVENTION, WHEN YOU ARE ABLE TO DO SOME PREVENTION WORK

WITH OLDER ADULTS WHO HOARD …..................................................................... 7-8
❺ PEER SUPPORT GROUP MODELS, HOW TO FORM AND FACILITATE A SUPPORT GROUP …… 9-10
❻ CRISIS INTERVENTION WORK/WHEN PROTECTIVE SERVICES IS INVOLVED …………………… 11-13
❼ THE CONCEPT OF A POINT PERSON AT ASAP’S …………………………………………………… 14 -15
❽ WHAT IS AVAILABLE FOR UNDER 60’S? WHAT IF A CLIENT IS 56? …………………………… 16 -17
❾ WHERE TO LOOK FOR FUNDING- WHO WILL PAY FOR HEAVY CHORE ...………………………. 18-19
❿ SELF-CARE FOR THE PROFESSIONAL- HOW TO TAKE CARE OF YOU ……………………………… 20
⓫ RESOURCES ………………………………………………………………………………………………… 21
 ⓬ APPENDIX …………………………………………………………………………………………………. 22-23

APPENDICES …………………………………………………………………………………………….. I - XX
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Hoarding: Best Practices Guide Winter 2012
Section ❶
Introduction:
Hoarding is a complex issue that affects people across age, socioeconomic, and racial lines. It is not only an
issue that affects the individual, but also the family and community. Research has shown that while the onset of
hoarding starts around age thirteen, the average person seeks treatment around age 50 (Bratiotis, Sorrentino &
Steketee, 2011).
It has been the committees’ experience that many people who hoard choose not to seek treatment and only come to
the attention of public agencies when they are considered older adults (60 and older in Massachusetts). The person
who hoards is not seeking treatment, but rather has been discovered by a mandated reporter or neighbor often due
to a fall, an incident such as a fire or odors emanating from their home. Once “discovered” the very private issue
that they have fought so hard to hide quickly becomes public. The individual is thrown into a swirl of decisions and a
multitude of people approaching them. This can lead to anxiety, frustration and fear causing many people who hoard
to shut down and refuse help. Unfortunately this reaction often leads to more involvement from protective services,
city officials and eventually the courts.
Without active participation from the person who hoards the courts often choose the option of a clean out of the
apartment/house, charging the resident, landlord or putting a lien on the home. The individual might also be forced
to leave their home and therefore become at risk of homelessness. While a clean out addresses the immediate
public health issue of hoarding, the recidivism rate is near 100% for a person who hoards without any type of
behavioral treatment (Bratiotis, 2011). Thus the cycle of acquiring and the failure to discard will begin again at some
point, leaving the professionals that tried to help frustrated and their agencies financially drained.
It is the Hoarding Best Practice Committee’s hope that this document will provide new information to the ASAPs and
other social agencies serving elders in the Commonwealth. Our aim is to offer our combined experience and
expertise to the field as we all strive to work with elders on this very serious issue that affects their physical and
emotional health and safety every day. This document is a collaboration of our experience and can be used as a
guide to effectively address the hoarding behavior of elders living in our communities while at the same time
respecting their dignity and self-worth.
We would like to thank everyone who helped us put together this handbook, with a special thank you to Greater
Lynn Senior Services Hoarding Project and Merrimack Valley’s Safer Homes Program, for sharing their work
documents with us and to Brenda Correia, Jonathan Fielding, Duamarius Stukes and Denise Bradley from the
Executive Office of Elder Affairs for their guidance throughout the project.
Sincerely,
Laurie Grant
Hoarding Best Practice Committee:
Chair, Laurie Grant, Greater Lynn Senior Services
Michele Martindale, Greater Lynn Senior Services
Deborah Schwendiman, Senior Care, Inc.
Dori Prescott, Senior Care, Inc.
Kim Flowers, Elder Service of Merrimack Valley
Kathleen Turner, Brookline Community Mental Health
Marnie McDonald, North Shore Elder Services
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 Section ❷
Hoarding: Persistent difficulty discarding or parting

with personal possessions, even those of apparently
useless or limited value…the large number of
possessions fill up and clutter the active living
areas…and prevent normal use of the
space…symptoms cause clinically significant distress
or impairment in social, occupational, or other areas of functioning… (Proposed DSM-5
Criteria for Hoarding Disorder, 2012).
WHAT IS HOARDING AND HOW DOES IT AFFECT A COMMUNITY

Nature and Extent of the Problem:
Research has shown that compulsive hoarding is a progressive and chronic condition that often begins early in life,
increasing in severity as individuals age (Ayers, et. al., 2009). Research also shows that hoarding has been an
underreported and poorly understood mental health condition (Muroff, Bratiotis & Steketee, 2010). According to
Bratiotis, Sorrentino & Steketee, 2011, 2-5% of the adult population suffer from the disorder. With the US
population in the 2010 census at 308.7 million (“state and county quick facts”, US Census Bureau) this puts the
prevalence of hoarding at 6-15 million people nationally. By comparison, the number of people with Alzheimer’s
nationally was 4 million people in 2009 according to the National Institute on Aging (as cited in San Francisco Task
Force on Compulsive Hoarding, 2009). This becomes an important issue facing communities whose older adult
population is also on the increase. Nationwide there was an increase of 15% in the population of people age 65 and
older from 2000 to 2010. This is expected to increase to 36% between 2010 and 2020. By 2030 there is expected to
be 72.1 million older adults nationally – almost twice the number in 2008 (US census).
For Example:
If the percentage of hoarders is indeed at 5 percent this means for example that in the communities that Greater
Lynn Senior Services serves there may be as many as five thousand, five hundred adults (5500) age sixty or over
dealing with the problem with that number expected to increase.
Hoarding continues to be an underreported mental health condition. A study done in Massachusetts showed that
only 26.3 hoarding-related complaints were filed per 100,000 residents in a five-year period (Frost, Steketee,
Williams, 2000).
For Example:
This number suggests that as few as 149.9 hoarding complaints may be made during a 5-year period in Essex
County, while research shows that the prevalence in the five GLSS catchment cities alone could be near to 5,500
older adults.
Several reasons may exist for the low number of reports or complaints around hoarding issues. The lack of reporting
may be due to a limited amount of community education about resources to combat the problem as well as stigma
around the behaviors. Victims tend to isolate with the problem, which usually only comes to attention when the
situation becomes dire (MassHousing Hoarding Resources, 2012).
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In the past year the members of GLSS’s Hoarding task force have identified only 38 adults,
age fifty or over dealing with the problem.
This indicates that many older adults with compulsive hoarding issues are likely still undetected.
Factors Contributing to the Problem

Compulsive hoarding is often associated with other debilitating mental health issues such as dementia, obsessive-
compulsive disorder, generalized anxiety disorder, attention deficit disorder, social phobias and depression. Many
times there are features of personality disorders such as avoidant, dependent and paranoid (MassHousing
Conference, 2007). These can be difficult disorders to treat and adding hoarding behaviors only makes it more
difficult. The research on effective treatment models is relatively new and at this point there is a limited amount of
knowledge in the mental health community on how to effectively treat the condition (Bratiotis, Schmalisch, &
Steketee, 2011). It is noteworthy that in a study done by Ayers, et al, (2010), only two out of eighteen participants
had ever sought treatment for their hoarding behaviors even though it dated back several decades and they had
sought psychiatric treatments for other mental health problems. This highlights the need for both mental health
providers and the general public to know where to turn for help for compulsive hoarding behaviors. Another factor
contributing to the problem is that hoarding is a chronic condition and requires not only skills training, but also on-
going support and accountability to maintain one’s success.
Impact of the Problem

Hoarding is clearly a public health issue. According to Bratiotis, Schmalisch & Steketee 2011 hoarding can lead to
direct health and safety risks to the individual, their family and their neighbors and can create considerable costs for
the community. In 2000 the Massachusetts Department of Public Health reported in a survey of health officers in an
area of 1.8 million residents, that four hundred and seventy one complaints were filed due to concerns about
sanitation, fire hazard, odor, odd behavior and three deaths due to fire- all likely related to hoarding behavior.
Fires that begin in a hoarder’s home are more difficult to extinguish making them more likely to be serious and to
spread to neighbor’s dwellings (Harris, 2010). As recently as March 2012 a Massachusetts’ elder perished in a fire
because firefighters were not able to reach him in time due to the amount of clutter and hoarded items blocking
their access.
In addition, infestations are another hazard that hoarders and their neighbors face. Due to the enormous amount of
clutter or possessions it can be nearly impossible to get rid of insects or rodents (Bratiotis, Schmalisch, & Steketee,
2011). A single heat treatment to remove bed bugs costs $1,000 per unit. In a hoarder’s home or apartment
treatment may need to be repeated several times to be effective. Cleanouts can cost as much as $16,000 or more
and may need to be repeated after one year if the hoarder has not received treatment for his behaviors
(MassHousing Hoarding Resources, 2012). For City, State or Federal Housing Authorities this can represent a
significant financial burden. For private homes the community costs for repeated visits from health inspectors or
other public agencies can also be quite high (Muroff, Bratiotis & Steketee, 2010). Due to the numerous problems
that accompany hoarding behaviors, victims are often at risk for eviction and homelessness (Muroff, Bratiotis &
Steketee, 2010; (MassHousing Hoarding Resources, 2012). Hoarding is actually one of the leading causes of eviction
besides non-payment of rent (MassHousing Hoarding Resources, 2012).
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Research also shows that individuals with hoarding behaviors are significantly more likely to suffer from chronic
medical conditions and obesity (Bratiotis, Schmalisch & Steketee, 2011), which makes organizing and de-cluttering
even more difficult for them. Additionally, having large amounts of clutter with increased dust, mold and pest
infestation as well as instability of the structure of their living spaces due to excess clutter, makes for a very
unhealthy living situation. They are also in danger of falling due to cluttered pathways. As a result hoarding behavior
poses an important health risk to its sufferers, particularly in the elderly population.
It is imperative that key areas are evaluated so that treatment interventions can be effectively
prioritized. The following are some of the more important areas for review:
Safety of the person (including any other

people living in the home and/or pets)
Safety of the Structure of the building to

person and others visiting the home
Insight of person regarding their situation
Capacity of the person to address the

hoarding
Resources, i.e. financial help to pay for

cleaning services, insurance to assist with
paying for mental health and local agencies
that may be able to assist
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 Section ❸
Hoarding Intervention Decision Tree
PERSON OR OTHERS IN THE HOME ARE IN DANGER
THERE IS CONCERN BUT NOT IN DANGER:
(SELF OR STRUCTURALLY):
REPORT TO: REPORT TO:
PROTECTIVE SERVICES (IF OVER 60) PROTECTIVE SERVICES AND/OR HOARDING
DISABILITY COMMISSION (UNDER 60) PROGRAM AT ASAP/LOCAL TASK FORCE
ANIMAL SERVICES (ANIMALS INVOLVED)
DEPT. OF CHILDREN AND FAMILY (CHILDREN)
PROTECTIVE SERVICES/HOARDING PROGRAM

ASSESSMENT MADE ON WHAT APPROACH TO TAKE:
DEMENTIA INSIGHT/MOTIVATION LITTLE INSIGHT NO INSIGHT/

[SECTION 6] [SECTION 4] AND MOTIVATION NO MOTIVATION
[SECTION 4] [SECTION 6]
HOME CARE SERVICES PREVENTION MODEL PREVENTION MODEL HARM REDUCTION CRISIS
SYSTEM OF SUPPORT CBT METHOD CBT METHOD INTERVENTION
[SECTION 9]
POTENTIAL PEER
SUPPORT GROUP
MEMBER
[SECTION 5]
WEEKLY/DAILY IN HOME WEEKLY OR EVERY WEEKLY INTENSIVE

SUPPORT OTHER WEEK MEETINGS W/CLIENT
MEETINGS W/CLIENT
MONTHLY CHECK-IN WITH TEAM MEETINGS

TEAM OF PROVIDERS WITH: ALL INVOLVED
MONTHLY CHECK-INS: (BOH, PROTECTIVE,
TO ENSURE SERVICE LANDLORD, HOARDING
DELIVERY IS EFFECTIVE/ OUTREACH) TO DISCUSS
WORKING MONITORING PLAN OF ACTION AND
W/CLIENT ROLES/ RESPONSIBILITIES
[SECTION 7]
MONTHLY … OR LESS
MONITORING BY
HOUSING, HOARDING
SOCIAL WORKER, OR
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COURTS
 Section ❹
EARLY INTERVENTION, WHEN YOU ARE ABLE TO DO PREVENTION WORK WITH OLDER ADULTS
WHO HOARD
 Pre-Meeting/Referral Process: Gather as much information as you can over the phone from the referring
person or the individual themselves. The more you know ahead of time the more you will be able to plan
your initial approach. It is also important to know the condition of the home and prepare for any precautions
you want to take when entering the home (more information Section 9). [Referral Form Appendix 1]
 Schedule the Initial Meeting: Depending on the person’s comfort level you might meet at their home,
the senior center, a park bench and it might just be a quick meet and greet or a full assessment and tour of
the home. Remember you are building a long-term relationship so it is ok to take it slow and show the
person that you are willing to partner in their clinical treatment/learning at their pace.
 Assessment Tools: This might include open ended questions, the Clutter Image Rating scale, the Hoarding
Interview, Activities of Daily Living Scale and general questions about what they are interesting in learning
and changing. [Assessment Tool - Appendix 2]
 Create a Service Plan Agreement Together: The service plan is used to formulize your partnership,
identify the overall goal (often to maintain safety in the home), and both short and long term goals. Both the
client and the professional sign the document to demonstrate that this is a joint effort and agreed upon plan
of action. Review and reference often. The agreement should be used to guide your sessions and work time
together. [Service Plan- Appendix 5]
 Establish and Plan Consistent Appointments: Mark the appointment date on a calendar in the person’s
home. It is a good practice to meet weekly/or every other week to start. Plan to move to once a month
monitoring or checking in when the goals have been met. Make sure that you show up on time for
appointments and model time management skills during your meetings. Make sure that the client knows
how to contact you if they need to cancel.
 Schedule 1 1/2 -2 Hour (max) Meetings: Make it clear what your role is- supportive, therapeutic, and
educational. You are not a heavy chore worker and this should be discussed at the beginning. With any type
of memory or personality issues roles are often confused and it is important to discuss with the client right
away so they are clear on what work you and others entering the home are there to perform.
 Heavy Chore, Homemaking, Companion Services, Therapy, Supportive Housing Assistance: These
issues should be discussed from the beginning as a possible means of accomplishing the individual’s short
and long term goals. Student interns and volunteers can also be used with clients who want to do the work
and need the accountability piece of having someone present in their home.
 If the Person Who Hoards is Actively Acquiring Start Your Work Here: You want to help the person learn
that without limiting the acquiring the de-cluttering work won’t go far.*
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 A Plan for Each Visit:

Check-In - Talk about homework, success/challenges. Make time to discuss challenges of the week and
what is holding them back. You might run through a visualization of the small area you are working on
together and the goals for that small area. Also talk about what it will look like and feel like after the
work is done.
Exposure Work - Work on an area for 30-40 minutes having the client do the hands on work. You are
helping the client build a tolerance for de-cluttering and showing them that they can in fact do the work.
Supporting, building their self-esteem, helping to stay focused and on task, and motivating the person to
work towards their goals is your role during exposure work.
Check-Out- How did it feel, what are goals for next week.*
 Areas to Target: Depending on the short and long term goals you will discuss the three areas of hoarding
work at each visit: acquiring, sorting and discarding.
 When is the Work Done: This is a difficult question. Simply put the work might never be done, at least for
the client. The first step for you to step out as the professional might be to move to meeting less frequently
from every two or three weeks to a once a month monitoring meetings. After that offer that you are
available for check-ins and to call if things build up at some time in the future. Success in hoarding work is
hard to define because everyone has a different view of what is good enough. If the client feels successful in
reaching their goals both short and long term and their home is safe and clear of health concerns then it is
time to step out and let them manage their “chronic condition” on their own. You as the worker need to be
careful and consistent on maintaining professional boundaries and not push your own agenda for your
client’s home. They are in charge and will only be successful if you let them know that their ideas matter.
We are not striving to create Martha Stewart, just safe and healthy homes … whatever that means to the
person with whom you are working with.
*Resources/Examples: What to do in sessions (the work) can be found on the reference page (Section 11)
“A Note on Notes”:
The depth of notes you document will depend on your agencies
requirements. In the very least keep a spreadsheet of clients and brief
notes on what was accomplished during your visit. You might also
want to keep a chart with important information and your notes that
you jot down during your visit and any other important information-
resources… You will also want to document to your agency how many clients you
worked with and the number who refused services.
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 Sction ❺
PEER SUPPORT GROUP MODELS, HOW TO FORM AND FACILITATE A SUPPORT GROUP
Support groups have been proven to be an integral part of the intervention and change process. The purpose of a
support group for hoarding behavior is to provide a safe and nurturing environment for individuals to share
experience, strength, and hope with each other in order to educate and support those who have symptoms of
compulsive hoarding. These groups are designed primarily for older adults with hoarding disorder who possess a
strong desire to change and manage their hoarding behavior and to improve their quality of life and maintain their
living space. According to Jordana Muroff, Ph.D., Boston University, “group interventions are good alternatives that
give more people access to clinicians and coaches who can help. Group methods may also be more affordable for
hoarding sufferers”. Additionally, Muroff reports that a recent study referencing facilitated support groups resulted
in “much improvement” of the hoarding behaviors by the group participants (Muroff et. al, 2010).
 Potential group members are interviewed 1:1 to determine fit, ability, and motivation to attend, participate,
and progress through entire group session.
 Self-report, including potential participants perspective of their living space based on the clutter image
rating tool and HOMES assessment are weighed in addition to interviewer questions and observation.
 Before final determination is made, a home visit will be made to ensure the living space conditions have
been reported accurately and that the conditions fall within the qualifying parameters of the clutter image
rating tool developed by the International OCD Foundation – [Hoarding Center and the HOMES Multi-
disciplinary Hoarding Risk Assessment tool – Appendix 6].
Example: The group model currently being used at North Shore Elder Services is Psycho-educational.
 The group is closed (meaning there are no new members after the first meeting) and runs for 15 weeks for 1
½ hours per group session.
 The integration of Cognitive Behavioral Therapy (CBT) theory with the Conceptual Model, that builds a
graphic depiction of the factors contributing to the hoarding behavior, is implemented.
 The techniques used (Conceptual Model) has members describe and discuss their physical and social
environment in order to better understand how both of these aspects affect their hoarding disorder.
 Group members are shown how to work through the thoughts and behaviors associated with their hoarding
both through the group process and homework assignments that are then discussed during the group.
Some More Thoughts on Groups:

 The group work guide from the work of Dr. Randy Frost (Maxner, et al. 2010) can be used as a best practice,
and then adapted to fit your community and populations unique needs. Groups are a great way to outreach
to communities that might be hesitant to discuss “hoarding”. Where you host the group can also be an
opportunity to outreach to a new community. There can be a trickle-down effect where other people who do
not choose to participate in the group still gather information and at least start to think about joining in the
future. The community also benefits by learning more about hoarding and the services your agency offers.
More referrals! Using a non-threatening name such as The De-Clutter Group or Clutter Bug Group helps
people get the assistance they need, while not being labeled as a person who hoards.
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At Greater Lynn Senior Services for example a closed psycho-educational group is held for 10 weeks, 2 hour
sessions with a 15-20 minute break. The group is limited to 8 members, although 5 is a comfortable number
that allows each member a chance to feel heard and supported. The book Buried in Treasure is used as a
guide for discussion with each member responsible for completing assigned exercises. The Beverly Hoarding
Task Force runs a closed group that lasts for six weeks. Pre-screening involves a phone call and contracting.
The sessions focus on learning new skills and reporting back to the group.
The crucial element in all three group work models is to increase insight and motivation and develop a
healthy relationship with one’s possessions.
Use of CBT (Cognitive Behavior Therapy) -

Much of the research has found that some
components of CBT can be useful (and
essential) in helping people change their
thinking patterns and relationships to
hoarding. This is especially true for
individuals with better insight and
capacity. Thoroughly understanding ones
underlying thoughts and motivations may
not be essential to make changes though.
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 Section ❻
CRISIS INTERVENTION WORK/WHEN PROTECTIVE SERVICES IS INVOLVED
The PS response should begin with harm reduction. It is important to engage both the elder and the referral source
to let each know that you can help. It will be a process, not always a quick fix.
If the elder is living in an environment that is an acute threat to health and safety for themselves or others, the
situation may require that the elder be removed from the home. This would be determined by local or housing
authorities, and the crisis intervention response would be to assist with alternative housing and seek to engage the
elder as described below to allow the PS worker to help the elder get the home into a state compliant with re-
habitation.
 If the referral was made by an enforcement authority, it is important that the screener and clinician are aware of
the conditions and consequences. A discussion with the referral source should precede contacting the elder. Any
plans to assist before enforcement should be laid out before discussing with the client.
 When talking to the referring authority, ask to focus on the steps needed to retain housing for the elder.
 Actions that need to be taken to enhance safety:

o Eliminate doors/windows blocked
o Eliminate heating vents that are blocked
o Remove food, trash that is attracting pests
o Eliminate areas that represent a fire risk
o Eliminate areas that represent a fall risk
o Areas that interfere with ADLs (Activities of Daily Living), such as bathroom, stove, refrigerator will
need to be addressed.
 Use the authority the client gives you to work with you to develop a timeline for addressing each issue so that
you can provide the elder with a reasonable and achievable action plan.
ENGAGING THE ELDER - BE AWARE THAT:
 92% of individuals with hoarding condition also have another co-occurring mental health disorder, such as
depression, anxiety, OCD or social phobia (Mass Housing Conference, 2007).
 These individuals often have difficulty managing their emotions and significant difficulty trusting others. They
may have been traumatized previously by a major clean out, and will be very reluctant to engage for any
assistance.
 Engaging the person is critical to working with them, and the elder should be approached in a non-
confrontational manner. It is imperative to explain the role of Elder Services and that you are there to assist with
making the home safe and help relieve the risks identified by the referral source.
 If the elder is not willing to engage, it is important to keep the option open for them to call for help later, as it can
take several contact episodes to develop enough trust for the elder to allow help.
 Explain that your agency is not part of the enforcement community, but rather is able to be an advocate for the
elder and may be able to help them with that issue, and that you may be able to meet with Housing (or other) to
get them to lay out a plan of action and work on it so that we can avoid further action.
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 If the client agrees to the investigation, then proceed with intake as appropriate for standard first home visit
protocol.
 The easiest way to engage, preserving the elder’s dignity and allowing them to participate most fully in deciding
how to move forward is to find an opening. This will allow you the opportunity to point out one or two critically
unsafe areas from a safety perspective. See what they think. It is best to address the risk areas first. This will
keep the process manageable for the elder and provide some incentive to engage.
 It is important that the elder is able to acknowledge an awareness of the problem and is able to see some
disadvantages of the status quo. They may not agree immediately to allow you to help, but you may be able to
start an initial action plan.
 Identify an action plan based on critical need:

1. Blocked egress
2. Fire hazard
3. Animal/human waste
4. Trash and spoiled food
5. Fall risk
6. Access risk for fire department
7. Any other issues from referral source
 The plan should be concrete and presented in small enough increments to get work done but also not overwhelm
the elder, risking refusal to cooperate.
 Action from here will vary depending on the agency involved:

1. Heavy chore through an agency knowledgeable about working with hoarding
 Explain the plan.
 Introduce the workers.
 PS worker should be present to facilitate the work and help the elder with anxiety that will come
up.
2. Agency hoarding program
 Plan weekly visits or more frequent if agency time allows and elder is willing to engage.
 Work according to the action plan, keep control as much as possible with the elder.
 A dumpster may be overwhelming or bring up feelings of embarrassment, so if a dumpster is necessary, plan a

short-term cleanout to minimize the time the dumpster is on the property to reduce stigma. A therapeutic clean-
out in which the person who hoards has some say and awareness of the work being performed is the preferred
method to a forced clean out without any involvement.
 As key milestones are reached, make a report to referring authority to develop a collaboration and show
progress, with the goal to reduce risk and increase likelihood that elder will be able to either remain in the home
or return as soon as possible.
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The “Carrot & Stick” -

Many researchers
have found that
increased outside
pressure can increase
the amount of change
that is able to take
place. The stick often
being the property
manager or public
health inspector and
the carrot being the
helping professional.
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 Section ❼
THE CONCEPT OF A POINT PERSON AT ASAP’S
Senior service agencies will benefit from hiring and/or contracting with a hoarding specialist/social worker. The
hoarding specialist/social worker is the point person for the area for all hoarding related cases. Referrals should be
received and processed by this individual. Based on the assessment the hoarding specialist/social worker will decide
what approach to use: early intervention or crisis/harm reduction (Section 3 and 4).
 Referrals come from Protective Services, Home Care, Housing, other agencies, family members or self-
referrals.
 Depending on the situation the point person will then schedule a meeting with the individual or go with
another person, such as the Protective Service Worker or Housing Service Coordinator on the first visit.
 Due to the complex nature of the work the point person will need to manage their time between initial visits
(building relationship and trust), one-on-one home visits* with individuals, outreach efforts, education and
advocacy, and playing a role in the local area community task force.
The hoarding specialist/social worker should also be part of, or chair the local area Hoarding Task Force. The Task
Force could have many functions based on the needs of the community. Time should be spent during meetings on
case consultation. It is the role of the point person to engage the key players and coordinate the community effort
and response towards the individual who is hoarding.
 A case consultation might include: Protective Service Staff, a Health Inspector from the Board of Health, the
City Building Inspector, Heavy Chore vendor, Department of Mental Health Case Manager, and Hoarding
Specialist. During the meeting the individual’s case is discussed and suggestions are offered on how best to
approach. By the end of the meeting a plan is established on the community response to the case- who will
write a letter, visit next, and what steps will take place to best reach/communicate the need for change with
the person who hoards.
 The Task Force should work towards community awareness of hoarding as a mental health issue and creating
a general understanding of what each discipline is able to do by law or regulation governing them, and what
their role can and should be when discovering a hoarding situation or when trying to work with a person who
hoards. Creation of a city wide protocol and understanding of how and where to report is a good place for a
task force to begin their work. Roles and Responsibilities of Police, Fire, Boards of Health, and Protective
Services are all crucial to understand. Connecting these key players to one another could mean the
difference between an organized, preventive response versus a crisis last minute effort to respond to a case
of hoarding.
 The Task Force members need to work as a team. Planning ahead of time who will give the violations (the
stick or bad cop) and who will offer the support (the carrot/good cop) in order to move forward in assisting
the individual.
 Other functions of the Hoarding Task Force could include: education for the community, outreach
presentations, advocacy and working on local and state policy change, and fundraising- monetary and in-
kind.
*The committee feels very strongly that when working with an elder who hoards you must do the majority of the
visits in the person’s home. Meeting in an office does little to show you how the individual is functioning at home
and does not show you how they are functioning with their activities of daily living.
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All agencies should identify staff in need of training and keep up to date on the protocol for responding to hoarding
cases. How and where to report is based on age and situation. Key players include but are not limited to: public
housing services coordinators, emergency responder’s such as; fire, police, Board of Health, EMT, building inspectors,
shelter directors, VNAs, DMH and DPPC, and Council on Aging Directors/outreach Staff.
Many people who hoard are extremely visual.

They often fear that if they put something away
they will not remember where it is because it is
not out in the open. A trick could be to label the
outside of a draw, a storage bin, or create a map
of where important items have been put away.
15 | P a g e
 Section ❽
WHAT IS AVAILABLE FOR UNDER 60’S?

WITH A YOUNGER CLIENT YOU WILL STILL USE THE FOLLOWING BEST PRACTICE STRUCTURE:
1) Assessment
2) Harm Reduction – assessment and intervention
3) Providers should be able to assess the home through a home visit and/or pictures.
4) Focus of interventions to target the three main areas of challenges including acquiring, discarding and
organizing.
5) Exposure to sorting (either in home or in office) and learning to recognize and manage the accompanying
anxiety for most people with hoarding.
6) Establishing a partner (home coach, professional organizer or supportive heavy chore person) who can
assist with in home work as outlined by the provider and person struggling with hoarding.
7) Funding to help pay for services if the person does not have access to financial resources.
DIFFERENCES WITH HOARDING AMONG YOUNGER VERSUS OLDER HOARDERS:
Increased challenges with elders include:
 Elders tend to have more collected items (because they have had more time to collect)
 Tend to have more risk of diminished physical and mental capacity (disease, dementia, etc.)
 Tend to have more losses (less people to assist, more loss reaction and less support)
 Elders have an increased risk of severe injury relating to a fall or topple hazard.
Thoughts on working with younger people under 60:
 Are often still working, raising their families, or taking care of an aging parent (limited time to work on de-
cluttering).
 Are more likely to access mental health services, but might not disclose hoarding to therapist if only seeing
her/him at their office.
 Might have more family/friend support. At the same time family/friends might not be aware of the extent of
the problem. Might not have been in person’s home for many years or ever.
 Have less access to funding streams that can help with home heavy chore and cleaning assistance.
Some of the most helpful agencies for people under 60 tend to include the following:
 The Department of Mental Health, especially in-home concrete services;

 Occupational Therapists - can often bill for in-home concrete skill building training which could include
sorting, discarding & organizing;
 Homelessness prevention and tenancy prevention programs including MBHP which has a specialized
hoarding intervention program;
 Mass Rehab Commission - Homecare Assistance Program can offer some in-home light cleaning assistance
which could assist the resident;
 Churches and friends can also be resources to help a person find additional assistance;
16 | P a g e
Challenges to Addressing Hoarding:
1. Lack of resources – not being

able to pay for a heavy chore worker
or ongoing cleaning services is a
challenge for many people who do
not qualify for very low income
programs.
2. Lack of counselors- individuals

trained to work with people who
hoard are limited.
3. Lack of reporting- first

responders need to report to
protective services as a means of
identifying people who are self-neglecting. Without the initial report hoarding stays
unknown until a crisis happens.
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 Section ❾
WHERE TO LOOK FOR FUNDING-WHO WILL PAY FOR ALL OF THIS?

The million dollar question that everyone wants to know is how will we pay for the services that my client needs. Not
only do we have a clinical/mental health issue here we also have a stuff issue and stuff takes time and effort to
remove.
Clinical Services: Private insurance and MassHealth will pay for a client to work with a mental health professional
for an in-office visit. Home visits are also covered, but only for the face to face time and limited to 50 minutes.
Travel time to and from the house is not reimbursable. The DSM-V set to be released in 2013 will allow hoarding to
be billed independently. While in-office counseling is beneficial, having someone come into your home and work
with you on exposure therapy is a very important piece of this work. ASAP’s and other agencies can support
clinician’s by finding ways to fund the additional time spent traveling to and from a person’s home and for the
increase time needed for a visit – at a minimum 1 ½ hours is suggested for an in-home visit. A combination of
in-home and office visits can also be used as described in the research from Boston University (Bratiotis, Sorrentino-
Schmalisch, Steketee, 2011).
Home Care/Heavy Chore/Organizing: If the client is over 60 a referral to Protective Services and/or home care
(when the client is ready) is entrance into the system. The amount of services available will vary. A sliding scale is
also available.
For People 65 and Older or a Frail Elder: SCO (Senior Care Options) works with people who hoard to provide
heavy chore services. SCO participants have MassHealth and Medicare.
For People 55 and Older and Who are Nursing Home Eligible: PACE (Program of All Inclusive Care for the
Elderly) provides an option for older adults for a wraparound program of care. Home care and heavy chore can be
part of this plan. Day programs provide an escape from social isolation and a chance to gain new interests and
connections to people.
Senior Centers and ASAP’s: These agencies often have funds available (small necessities or scholarships) to pay
for a one time clean out/planned with the consumer or removal of items, or more.
Department of Mental Health (DMH): Does the client qualify for DMH services? If so, DMH is a potential option for
service delivery. If already a client, the community worker might have the best relationship and can be trained to
work with the client on discarding.
Student Interns: Psychology, Mental Health, Social Work, Human Services students can be a great resource for
helping clients work in the home with supervision by a professional.
Peer Support: Pairing up two or more clients to help each other. Sometimes just the accountability piece is needed
and clients can help each other by just being present in their home while the other does the work. Often times peer
support will be an outcome of a peer support group.
Volunteers: It is true some people love to organize or are trying to start a business and want to offer some pro bono
assistance. It is also possible to find volunteers, but they should be closely supervised and back ground checked
[Suggested Tools - Appendices 6 – 9].
18 | P a g e
Thinking Creatively/Outside the Box: Inventive thinking is needed for a big one-time clean out (if and when the
person is ready). You can often find coworkers, high school/college volunteers, AmeriCorps volunteers, etc.
Executive Functioning Skills -

Assessing and enhancing these
areas have been found to be
very effective in helping with
organizing deficiencies. Many
people who struggle with
hoarding have difficulties in
these areas of organizing.
Helping a client enhance
concrete skills (i.e. using a
calendar, time management,
and setting goals can be very
helpful.
19 | P a g e
 Section ❿
SELF-CARE FOR THE PROFESSIONAL- TAKING CARE OF YOU
 Have all first responders become familiar with H.O.M.E.S. assessment [Appendix 6], as a
means of being aware of environmental and structural risks to self and others.
 Make available to employees: masks, booties, plastic gloves, hazmat suits when needed
to evaluate the hazards or potential hazards. Vicks or other sprays are a way to help you
deal with odors in a home. Bring a clip board to help with taking important notes from a
standing position.
 For safety reasons keep your cell phone and keys with you and available- in your pocket or clipped to your
clip board. Make sure someone at your office knows the address/client you are visiting. Depending on your
comfort level bring another person or ask the individual to meet outside. Trust your gut feeling.
 If you must bring a bag into someone’s home, fill it with items you think you might need (plastic gloves, pen,
water bottle, etc.). You can also wear a fanny pack so you do not have to put your bag down. When you
return to your car an option is to place the bag into a plastic container or trash bag in your trunk.
 Wear clothes and shoes that you can place immediately in the washing machine when you return home, and
bring a change of clothes /shoes if you have multiple visits that day or are returning to the office if you
suspect or are told there are mice/bugs.
 Keep trash bags to place your closed toe shoes (bring another pair) and tie them up if possible after a visit.
Wet wipes are useful to keep in your car for a quick wipe down of yourself or bag if you feel it is needed.
 Utilize Fire Prevention Services, the Board of Health and/or Building Inspection Services to assist you if you
notice that there are broken or no smoke detectors, blocked egresses, oxygen and smoking, broken windows
or you are fearful of the air quality, ammonia levels due to animals or more.
 Once again …trust your gut feelings. If the home is beyond your comfort level ask the individual if you can
meet outside on a bench, or sit on the front porch. You could also meet at a coffee shop or at the senior
center. Let the person know that although they might be perfectly comfortable in their home, you are not
due to … (be very specific). It is ok to say this and continue to work together. Chances are the client is aware
that they need to make a few changes to their home. Hearing you say it might inspire them to take that first
step.
 Create a peer support group for yourself as a worker to discuss cases, concerns, and frustrations and offer
support on cases. Create a space where you feel safe to speak and receive feed-back on new ideas to try
during these often long and complicated cases.
 The Hoarding Task Force should schedule multi-disciplinary conferences to offer continued education and
share best practices for the community involved with people who hoard.
Concrete Reminders –Many people with hoarding have wavering insight as well as memory challenges.
When working with older clients using concrete written agreements, concrete goal setting, weekly
homework, developing rules for discarding or acquiring can greatly assist with treatment. One example
of rule development may include: any newspaper that is more than 3 months old can be discarded –
except for the health section on Mondays. Or an acquiring rule may be – “if I pick up one thing – I need to
discard at least two things from my apartment.”
20 | P a g e
 Section ⓫
RESOURCES AND HOARDING TASK FORCES
Age at onset and clinical features of later life compulsive hoarding. Ayers, C.R., Saxena, S,. Golshan, S., & Wetherell,
J.L. (2010). International Journal of Geriatric Psychiatry, 25 142-149.
Beyond overwhelmed. The impact of compulsive hoarding and cluttering in San Francisco and recommendations to
reduce negative impacts and improve care, archived at
http://mentalhealthsf.org/documents/BeyondOverwhelmed.pdf
MassHousing Hoarding Resources, (2012) www.masshousing.com/hoarding
Household Hoarding and Residential Fires - Paper presented at the International Congress of Applied Psychology,
Melbourne Australia, Harris, J. (2010, July).
Buried in Treasure. Tolin, D., Frost, R., Steketee, G. (2007). Oxford University Press
Digging Out. Tompkins, Michael A. and Hartl, Tamara. (2009.) New Harbinger Publications.
Hoarding: a community health problem. Frost, R., Steketee, G., Williams, L. (2000). Health and Social Care in the
Community. 8,229-234.
Leading a Self-Help Support Group for People Who Hoard: A Facilitator’s Manual. Maxner, S., Glossner, K.,
Sinopoli, N, Spencer, R, Pekareva-Kochergina, A, Frost, R. (2010). Smith College.
The Hoarding Handbook: A Guide for Human Service Professionals, Bratiotis, C., Sorrentino-Schmalisch, C. and
Steketee, G . (2011) Oxford University Press.
Stuff. Frost, R., and Steketee, G. (2010). Houghton Mifflin Harcourt
Treatments for Hoarding Behaviors: A review of the Evidence. Muroff, J., Bratiotis, C., Steketee, G. (2011). Clinical
Social Work, 39, 406-423.
Treatments that Work: Compulsive Hoarding and Acquiring Workbook. Steketee, G. and Frost, R. (2007) Oxford
University Press.
Treatments that Work: Compulsive Hoarding and Acquiring a Therapist Guide. Steketee, G. and Frost, R. (2007)
Oxford University Press.
WEBSITES:
www.ocfoundation.org/hoarding Information on hoarding and Obsessive Compulsive Disorder
www.childrenofhoarders.org Offers an on-line support group for children of hoarders
www.squalersurvivors.com Squalor and its effects on individuals and communities
http://www.stoppests.org/ Advice for bed bugs in housing
21 | P a g e
APPEN DICES
22 | P a g e
 Section⓬
APPENDICES TABLE OF CONTENT
Appendix # Page
1. Sample Referral Tool ……………………………………………………………………. I - II

2. Sample Assessment Tool ………………………………………………….…………….. III - IV
3. Clutter Imaging Rating Scale …………………………………………………………… V - XII
4. Sample Consent for Services Tool ………………………………………………….. XIII
5. Sample Service Plan ……………………………………………………………………….. XIV
6. Multi-disciplinary Hoard Risk Assessment ………………….……….………… XV – XVII
7. Sample Volunteer Welcome Sheet …………………………………………….……. XVIII
8. Sample Volunteer Coordinator Agreement ……………………………………… XIX
9. Sample Volunteer Visit Report ……………………………………………………….. XX
10. Sample Volunteer Donate/Discard Report …………………………………….. XXI
23 | P a g e
SAMPLE REFERRAL FORM [APPENDIX 1]
REFERRAL DATE: ___________________
REFERRAL SOURCE:
Name of Referring Person: _______________________ Agency/Relationship: _________________________________
Phone Number: _________________________________ Email: _____________________________________________
Is Client Aware of Referral: Yes  No
Level of Risk: Low Medium High Explain: __________________________________________________
Any Risk to Worker: _________ Explain: ________________________________________________________________
CLIENT INFORMATION:
Name: ____________________________ Phone: _______________________ OK to Call? Yes  No
Address: __________________________ City/State: _____________________________________________
E-mail: ____________________________ Language Spoken: ____________________ DOB: _____________
Marital Status:  Married  Widowed  Divorced  Single Veteran: Yes  No
Other people living in the home/relationship to client: ____________________________________________
________________________________________________________________________________________
Condition of the home: _____________________________________________________________________
Pets in the home: Yes  No How many/what kind: ________________________________________
Are there insects/rodents in the home: Yes  No If yes, what kind: _____________________________
Are there weapons in the home: Yes  No If yes, what type _____________ Stored away: _________
Insurance –include numbers Primary: _______________________ Secondary: ________________________
Medications: ______________________________________________________________________________
Health concerns: ____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
[TOOL PAGE 1 OF 2]
I|Page
Memory Loss: Yes  No Explain: _______________________________________________________
Loss/Stressors: __________________________________________________________________________
Present or Past Substance Abuse: Yes  No Explain: _______________________________________
Current or Past Mental Health Treatment: ______________________________________________________
Current Therapist, Counselor, Psychiatrist, Psychologists or Social Worker: _____________________________
SUPPORT SERVICES:
Current PS Client: Yes  No PSW Name: ________________________________________________
Current HC Client: Yes  No CM Name: ______________________________________________
Past client of GLSS: Yes  No How? _______________________________________________________
Other Services in the Home: ________________________________________________________________
Friends/Family in the Area: _________________________________________________________________
Emergency Contact Name: ________________________________ Phone: __________________________
PRESENTING ISSUE: Descriptive reason for referring client to program (include time/dates of incidents):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
ADDITIONAL INFORMATION: _______________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
REFERRAL FORM COMPLETED BY: _________________________ DEPT: ______________________________
DATE RECEIVED/REVIEWED: _________ BY: _____________________ PROGRAM: _______________
SCREENED IN FOR INITIAL VISIT/ASSESSMENT _________________ MEETING DATE/TIME ____________
SCREENED OUT ________________ REFERRED TO: _______________________________________
II | P a g e
SAMPLE ASSESSMENT FORM [APPENDIX 2]
DATE: ______________________
CLIENT NAME: ______________________________ LIKES TO BE REFERRED TO: __________________
ADDRESS: _________________________________ CITY/ZIP: _____________________________
PHONE: ___________________________________ E-MAIL: ______________________________

PLEASE CHECK ALL THAT APPLY ()
BEST TIME TO WORK TOGETHER:  Morning  Afternoon  Late Afternoon
HOUSEHOLD:
 Single Family  Market Apartment  Subsidized Apartment  Senior Housing  Multi-Family
Other: ____________________________________
1. How long have you lived at your current residence: ____________________________________________

Prior Residence: _________________________________________________________________________
2. Does anyone else live with you in your home? Yes  No

If yes, who: ___________________________________________________________________________
3. Are you currently seeing a therapist, counselor, psychiatrist, psychologists, or social worker for any
reason? Yes  No
If yes, who: ____________________________________________________________________________
4. Have you ever received any previous mental health treatment? Yes No
Where? _____________________________________________________________________________
5. Have you worked with anyone in the past, attempting to process your belongings? Yes No
If yes, who: __________________________________________________________________________
How did they work out? ____________________________________________________________
6. Do you have conditions that limit your physical mobility?  Yes  No

If yes, explain: ________________________________________________________________________
_____________________________________________________________________________________
[Tool Page 1 of 2]
III | P a g e
7. Are you on any medications?  Yes  No

If yes, what? ___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
8. Are there any animals present in your home?  Yes  No

If yes, how many/what kind? ____________________________________________________________
9. Are there any weapons in your home? Yes  No

If yes, what and where are they? _________________________________________________________
PERSONAL:
1. What do you value, what is important to you: _________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
2. Interest/hobbies:________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Education:_____________________________________________________________________________
4. Did you work outside the home?___________________________________________________________
5. Likes: ________________________________ Dislikes: _____________________________________

________________________________ ______________________________________
________________________________ ______________________________________
________________________________ ______________________________________
________________________________ ______________________________________
IV | P a g e
SAMPLE CLUTER IMAGING RATING SCALE (APPENDIX 3)
The following questions help me understand how the clutter affects you.
Please answer honestly. There are no right or wrong answers.
CLUTTER IMAGE SCALE RATING: At beginning, middle and end of work together __________
Client rates and Hoarding Specialist rates __________
CLUTTER INTERVIEW:
To what extent do you find it difficult discarding ordinary things that other people would get rid of?
 Not at all Difficult  Mildly  Moderately  Extremely Difficult
Because of the clutter or number of possessions, how difficult is it for you to use the rooms in your home?
To what extent do you currently have a problem with collecting free things or buying more things than you
need or can use or can afford?
To what extent do you experience emotional distress because of clutter, difficulty discarding or problems with
buying or acquiring things?
NOTES:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
V|Page
[Tool: Page 1 of 8]
PLEASE INDICATE THE EXTENT TO WHICH CLUTTER INTERFERES WITH YOUR ABILITY TO DO EACH OF
THE FOLLOWING ACTIVITIES: Circle corresponding numbers
Can Do
Activities of Daily Can Unable Comments
N/A With
Living Do to Do
Difficulty
Prepare Food (cut
0 1 2 3
up food, cook it)
Use Refrigerator 0 1 2 3
Use Stove 0 1 2 3
Use Kitchen Sink 0 1 2 3
Eat at Table 0 1 2 3
Move Around
0 1 2 3
Inside of House
Exit Home Quickly 0 1 2 3
Use Toilet (getting
0 1 2 3
to the toilet)
Use Bath/Shower 0 1 2 3
Use bathroom Sink 0 1 2 3

Answer Door
0 1 2 3
Quickly
Sit on Your Sofas
0 1 2 3
and Chairs
Sleep in Your Bed 0 1 2 3
Clean the House 0 1 2 3
Do Laundry 0 1 2 3
Find Important
0 1 2 3
Things (bills)
Care for Animals 0 1 2 3
VI | P a g e
SUPPORT NETWORK:
1. Do you have family/friends in the area?  Yes  No

If yes, who: ____________________________________________________________________________
2. Does anyone get upset by your collecting and clutter or do they mostly tolerate it?
________________________________________________________________________________________
_________________________________________________________________________________________
3. Do your family members or friends help you get items or store them for you? ______________________
_________________________________________________________________________________________
4. Does anyone help you organize things you can’t deal with? _____________________________________
________________________________________________________________________________________
5. Do you prevent others from touching your things? ____________________________________________
________________________________________________________________________________________
6. Are your family members or friends supportive of you getting help/treatment? If so, would any of them be
interested in coming with you to a session? ____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
TO ACCOMPLISH AT THE FIRST FEW MEETINGS:

ISSUES WITH CLUTTER:
1. Are you currently involved with anyone (landlord, housing court, board of health, fire dept.) because of the
clutter in your home?  Yes  No
If yes, explain:
_____________________________________________________________________________________
2. What kind of things do you save? ___________________________________________________________
______________________________________________________________________________________
3. Describe to me your emotions when you look at or think about the clutter? (e.g. anxiety, guilt, sadness,
happiness)_______________________________________________________________________________
VII | P a g e
4. How much discomfort would you feel if you had to get rid of some of your __________________________
(Ask about Each Category of saved items) with 0 being no discomfort to 100 being the most you have ever
felt.
5. Let’s talk about the rooms in your home. How much does clutter interfere with how you’d like to use
each room and which rooms bother you the most? (Let client guide you through the home.. compliment at
least one item (a nice photo or lamp…).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
VIII | P a g e
MOVING TOWARDS A SERVICE PLAN:
1. Are you ready to work with me your (identify yourself as a “worker”,” coach, assistant”…connecting
yourself with that person) “_________________”on sorting through things in your home?  Yes  No
If no leave information and tell the person they can call you when they are ready, and that you will also
check in with them in the future. If yes the work begins.
2. What should we call the work that we are doing together? (Sorting, looking through treasures, recycling…)
______________________________________________________________________________________
3. Identify the role you will play- I am going to meet with you to help you go through your stuff and process
what you will keep, donate, or throw away. My role is to help you learn why these items are important to
you- and to prioritize what is safe to keep and what we can eventually part with to make your home more
(livable, help you to relax, get housing off your back, ease tension between you and family…) My job isn’t
to clean your apartment or organize for you. We will work as a team and talk about everything while we
are going through things. I promise not to touch anything, or throw anything away without discussing it
with you. I am your _____________ (Identity from Question 1). Each time we meet we will first sit
down and discuss the work we have done and our goal for the day. At the end of every meeting we will sit
down again and discuss what we accomplished and what we will focus on the next time we meet. I might
also give you homework assignments to test what you have learned during our session.
4. Are you ok with us taking photos of the work we do together? Photos are a good way to see the progress
that is made. Often times we don’t give ourselves enough create for the work that we do and a photo says
a thousand words.  Yes  No (If yes have client sign Release Form)
5. Let’s create our first service plan together. (Use Service Plan Agreement Form)
TOOLS TO USE DURING VISITS:

You may also use this as a checklist
 Service Plan Agreement- Have client sign
 Photo and release of information form
 Readiness to Change Questionnaire… if not getting anywhere
 Use workbook for Compulsive Hoarding and Acquiring- Steketee and Frost
 Savings Inventory
 Clutter Visualization and Unclutter Visualization
 Clutter Image Scale
 Saving Cognitions Inventory
 Downward arrow
 Practice form for homework
 Behavioral experiment form
 Thought record
 Refer often to the service plan-
IX | P a g e
Home > Academics> Departments & Programs > Psychology > Faculty & Staff
RANDY O. FROST
Professor
Clutter Image Rating
X|Page
XI | P a g e
XII | P a g e
[Tool: Page 8 of 8]
SAMPLE CONSENT FOR SERVICES [APPENDIX 4]
I ___________________ agree to work with ________________ on the projects listed below.

We have agreed to work together on _______________________on a ______________basis.
Date/Time Timeframe
I agree to use the sessions to learn why I hold onto things in my home and develop organizing,
prioritizing and functioning/systems skills. I understand that ______________ and I will work
together processing through my belongings, and that it is my decision what I discard. I agree
to work on homework assignments between sessions. This agreement is a fluid document and
can be adjusted throughout our work together. We will review if we will continue to work
together in 30 days, 60 days, and during a 6 month review.
Overall Goal of Work Together:___________________________________________________

_____________________________________________________________________________
Revised Goal _______:__________________________________________________________

Date
_____________________________________________________________________________
Achieved Goal _______:_________________________________________________________

Date
_____________________________________________________________________________
___________________________________ _________________________
NAME DATE
___________________________________ _________________________
NAME DATE
XIII | P a g e
SAMPLE SERVICE PLAN [APPENDIX 5]

Short-Term Interventions: (30-60 Days) This should include any immediate safety issues to be addressed.
____________________________________________________________________ Achieved: ______
_____________________________________________________________________ Achieved: ______
_____________________________________________________________________ Achieved: ______
Short-Term Coping Techniques to Use: (30-60 Days)

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Long-Term interventions: (60 Days- 6 Months) Include less immediate concerns, which may require intensive
work, coordination of additional services…
____________________________________________________________________ Achieved: ______
_____________________________________________________________________ Achieved: ______
_____________________________________________________________________ Achieved: ______
Long -Term Coping Skills to Work on and Develop: (60 Days to 6 Months)
______________________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
XIV | P a g e
MULTI-DISCIPLINARY HOARD RISK ASSESSMENT [APPENDIX 6]
HOMES® Multi-disciplinary Hoarding Risk Assessment

Instructions for Use
HOMES Multi-disciplinary Hoarding Risk Assessment provides a structural measure through

which the level of risk in a hoarded environment can be conceptualized.
It is intended as an initial and brief assessment to aid in determining the nature and
parameters of the hoarding problem and organizing a plan from which further action may
be taken-- including immediate intervention, additional assessment or referral.
HOMES can be used in a variety of ways, depending on needs and resources. It is

recommended that a visual scan of the environment in combination with a conversation
with the person(s) in the home be used to determine the effect of clutter/hoarding on
Health, Obstacles, Mental Health, Endangerment and Structure in the setting.
The Family Composition, Imminent Risk, Capacity, Notes and Post-Assessment sections are
intended for additional information about the hoarded environment, the occupants and
their capacity/strength to address the problem.
©Bratiotis, 2009. [The HOMES Assessment was developed in conjunction with the Massachusetts Statewide Steering Committee on Hoarding.
Information about the assessment can be found in Bratiotis, Sorrentino Schmalisch,& Steketee, 2011. The Hoarding Handbook: A Guide for Human
Service Professionals. Oxford University Press: New York.]
[Tool: Page 1 of 3]
XV | P a g e
HOMES® Multi-disciplinary Hoarding Risk Assessment
 Health
Cannot use bathtub/shower Cannot prepare food Presence of spoiled food Presence of insects/rodents
Cannot access toilet Cannot sleep in bed Presence of feces/Urine (human or animal) Presence of mold or
Garbage/Trash Overflow Cannot use stove/Cannot locate medications or equipment chronic dampness
fridge/sink
Notes: ______________________________________________________________________________________________________
______________________________________________________________________________________________________
 Obstacles
Cannot move freely/safely in home Unstable piles/avalanche risk
Inability for EMT to enter/gain access Egresses, exits or vents blocked or unusable
Notes: _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
 Mental health (Note that this is not a clinical diagnosis; use only to identify risk factors)
Does not seem to understand seriousness of problem Defensive or angry Unaware, not alert, or confused
Does not seem to accept likely consequence of problem Anxious or apprehensive
Notes: ______________________________________________________________________________________________________
____________________________________________________________________________________________________________
E
 ndangerment (evaluate threat based on other sections with attention to specific populations
listed below)
Threat to health or safety of child/minor Threat to health or safety of person with disability
Threat to neighbor with common wall Threat to health or safety of older adult
Threat to health or safety of animal
Notes: _____________________________________________________________________________________________________
___________________________________________________________________________________________________________
S
 tructure & Safety
Unstable floorboards/stairs/porch Leaking roof Electrical wires/cords exposed No running water/plumbing problems
Flammable items beside heat source Caving walls No heat/electricity Blocked/unsafe electric heater or vents
Storage of hazardous materials/weapons
Notes: _____________________________________________________________________________________________________
__________________________________________________________________________________________________________
© Bratiotis, 2009
XVI | P a g e
HOMES® Multi-disciplinary Hoarding Risk Assessment (continued)
Household Composition
# of Adults: __________ # of Children: ________________ # and kinds of Pets: ______________________________
Ages of adults: ________ Ages of children: ______________________ Person who smokes in home:
Person(s) with physical disability: ___________________________ Language(s) spoken in home: __________________
Assessment Notes: __________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Risk Measurements
Imminent Harm to self, family, animals, public: __________________________________________________________
Threat of Eviction: ________________________________ Threat of Condemnation: _________________________
Capacity Measurements
Instructions: Place a  by the items that represent the strengths and capacity to address the hoarding problem:
Awareness of clutter
Willingness to acknowledge clutter and risks to health, safety and ability to remain in home/impact on daily life
Physical ability to clear clutter
Psychological ability to tolerate intervention
Willingness to accept intervention assistance
Capacity Notes: ___________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Post-Assessment Plan/Referral: _____________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date: ____________ Client Name: __________________________ Assessor: _________________________________
© Bratiotis, 2009
XVII | P a g e
SAMPLE WELCOME TO THE VOLUNTEER HOARDING OUTREACH PROGRAM [APPENDIX 7]
Welcome to the Volunteer Hoarding Outreach Program. This program pairs you with an elder who has
expressed interest in working with a volunteer (helper) to make their home safer and more organized. You will
be assisting elders in clearing out some clutter, organizing paperwork, collections, clothing and other
belongings. Our agency is very happy to welcome you to the program, and appreciates your participation in
this important program.
What will happen:
You will be assigned to a particular elder to help them with the work they want to do. You and the elder will
work out a schedule that works for both of you, usually once a week.
Our program manager, _______________________ will set up a meeting to introduce you to your elder, and
the three of you will talk to plan where the elder would like to start working and what they want to
accomplish. With your help, the elder will work on the areas that are important to their safety and peace of
mind, at a pace that feels comfortable for the elder.
You will help the elder sort through their things, decide what to keep, give away or throw away, and you will
take things away as the elder agrees. Many organizations can make good use of donations, and the program
manager will help your determine the best organization for the elder’s donations.
What you will do:
You and your elder will plan a day and time to meet each week. It’s very important that if you are not able to
meet at the scheduled time, you let the elder know as early as possible and reschedule.
You and your elder will decide each week what you want to get done that week, and you’ll work on it for the
planned amount of time, usually 1-2 hours.
Call the elder a day or two before your scheduled visit to remind her of the plans.
You and the elder will work on sorting, organizing and arranging things, to make sure the home is safe to walk
around in, to use the appliances and furniture, and clear out the clutter the elder is ready to be rid of.
If the elder has trash, please help get it ready to throw out or recycle. If it’s close enough to trash day, or if
there is a dumpster available, please help get the trash out.
It’s not always easy to decide to get rid of things one may have had for years. The most important role you will
play is talking to the elder about what these items mean for them, the memories attached, and help them
make the best decisions for safety and peace of mind!
Good luck, and have FUN!!!!!
XVIII | P a g e
SAMPLE VOLUNTEER PROGRAM COORDINATOR AGREEMENT [APPENDIX 8]
In the spirit of service and respect for elders in the Hoarding Outreach Program, we recognize that the volunteers in this
program are an important part of the program. We also recognize that establishing this agreement of rights and
responsibilities of both the volunteer and the agency provides a mutually understood foundation for the program.
Acknowledging this, volunteers and coordinators are required to review and sign this agreement.
Volunteer:
 As a volunteer in the Hoarding Outreach Program, I agree to work under the supervision of the program coordinator
to carry out my assigned duties diligently and responsibly.
 I will attend scheduled orientation and training meetings.
 I will treat in strict confidentiality any information concerning a client with whom I am working, discussing issues only
with appropriate program or agency staff.
 I will submit to the program coordinator weekly visitation reports and lists of items removed from the client’s home.
 I will inform the program coordinator if I expect to be unable to visit the client for more than 2 weeks, and I will inform
the coordinator if I plan to terminate my volunteer activity.
 I will not enter into any relationship with the client which could be viewed as a conflict of interest, including any
relationship related to my business or personal life.
 I will not accept loans or gifts from a client.
 I will make no loans or gifts to the client.
 I will refrain from giving the client advice on health care issues or property related matters.
Program Coordinator:
I recognize the responsibility to ensure that volunteers have the support needed to do their work, and I agree to the
following terms:
 I will respect the volunteer’s contribution of time and skills by providing meaningful work assignments and by giving
serious attention to any problem identified by the volunteer.
 I will provide initial and on-going training for the Hoarding Outreach Program.
 I will provide assistance and supervision to the volunteer by maintaining regular communication through in-person
contact, periodic meetings, phone calls, email and letters.
 I will be available to answer questions an assist with resolution of specific problems.
 I will respect the schedule of the volunteers and will be available at the times we have arranged. I will contact the
volunteer if a schedule change is necessary.
Volunteer: _________________________________ Date: ____________________
Program Coordinator: _________________________ Date: ____________________
XIX | P a g e
SAMPLE VOLUNTEER VISIT REPORT [APPENDIX 9] Date: _______________
Volunteer: ___________________________________ Client: ___________________________________
Date of Visit: _________________________________ Time Spent: _______________________________
Client’s Appearance & Demeanor: _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
De-Cluttering Activity in Session: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Items Discarded or Donated: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
Concerns or Comments: _____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Next Scheduled Visit: ________________
XX | P a g e
SAMPLE VOLUNTEER DONATE/DISCARD REPORT [APPENDIX 10]
Volunteer: ___________________________________ Client: ___________________________________
Date of Visit: _________________________________ Time Spent: _______________________________
Items Discarded or Donated: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Client Signature: _________________________________ Date: ____________________
Volunteer Signature: _________________________ Date: ____________________
XXI | P a g e

Hoarding BestPracticeGuide

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Hoarding: Best Practices Guide

Hoarding: Best Practices Guide

❷ WHAT IS HOARDING AND HOW DOES IT AFFECT A COMMUNITY …………………………..….. 3-5

❸ DECISION TREE ……………………………………………………………………………………………. 6

❹ EARLY INTERVENTION, WHEN YOU ARE ABLE TO DO SOME PREVENTION WORK

❻ CRISIS INTERVENTION WORK/WHEN PROTECTIVE SERVICES IS INVOLVED …………………… 11-13

❼ THE CONCEPT OF A POINT PERSON AT ASAP’S …………………………………………………… 14 -15

❿ SELF-CARE FOR THE PROFESSIONAL- HOW TO TAKE CARE OF YOU ……………………………… 20

 ⓬ APPENDIX …………………………………………………………………………………………………. 22-23

Hoarding: Persistent difficulty discarding or parting

WHAT IS HOARDING AND HOW DOES IT AFFECT A COMMUNITY

Factors Contributing to the Problem

Impact of the Problem

Safety of the person (including any other

Safety of the Structure of the building to

Insight of person regarding their situation

Capacity of the person to address the

Resources, i.e. financial help to pay for

PROTECTIVE SERVICES/HOARDING PROGRAM

DEMENTIA INSIGHT/MOTIVATION LITTLE INSIGHT NO INSIGHT/

WEEKLY/DAILY IN HOME WEEKLY OR EVERY WEEKLY INTENSIVE

MONTHLY CHECK-IN WITH TEAM MEETINGS

 A Plan for Each Visit:

Some More Thoughts on Groups:

Use of CBT (Cognitive Behavior Therapy) -

 Actions that need to be taken to enhance safety:

ENGAGING THE ELDER - BE AWARE THAT:

 Identify an action plan based on critical need:

 Action from here will vary depending on the agency involved:

 A dumpster may be overwhelming or bring up feelings of embarrassment, so if a dumpster is necessary, plan a

The “Carrot & Stick” -

Many people who hoard are extremely visual.

WHAT IS AVAILABLE FOR UNDER 60’S?

DIFFERENCES WITH HOARDING AMONG YOUNGER VERSUS OLDER HOARDERS:

Increased challenges with elders include:

Thoughts on working with younger people under 60:

 The Department of Mental Health, especially in-home concrete services;

Challenges to Addressing Hoarding:

1. Lack of resources – not being

2. Lack of counselors- individuals

3. Lack of reporting- first

WHERE TO LOOK FOR FUNDING-WHO WILL PAY FOR ALL OF THIS?

Executive Functioning Skills -

MassHousing Hoarding Resources, (2012) www.masshousing.com/hoarding

Stuff. Frost, R., and Steketee, G. (2010). Houghton Mifflin Harcourt

APPENDICES TABLE OF CONTENT

1. Sample Referral Tool ……………………………………………………………………. I - II

Phone Number: _________________________________ Email: _____________________________________________

Is Client Aware of Referral: Yes  No

Level of Risk: Low Medium High Explain: __________________________________________________

Any Risk to Worker: _________ Explain: ________________________________________________________________

Name: ____________________________ Phone: _______________________ OK to Call? Yes  No

Address: __________________________ City/State: _____________________________________________

E-mail: ____________________________ Language Spoken: ____________________ DOB: _____________

Marital Status:  Married  Widowed  Divorced  Single Veteran: Yes  No

Other people living in the home/relationship to client: ____________________________________________

Condition of the home: _____________________________________________________________________

Pets in the home: Yes  No How many/what kind: ________________________________________

Insurance –include numbers Primary: _______________________ Secondary: ________________________

Health concerns: ____________________________________________________________________________

Phone Number: _ Email: _____________

Any Risk to Worker: _ Explain: ________________________________________________________

Name: ______ Phone: _ OK to Call? Yes  No

Address: City/State: ___________________

E-mail: ________________ Language Spoken: DOB: _

Insurance –include numbers Primary: _ Secondary: __

Emergency Contact Name: ______ Phone:

REFERRAL FORM COMPLETED BY: _ DEPT: ______

DATE RECEIVED/REVIEWED: _ BY: _ PROGRAM: ___

SCREENED IN FOR INITIAL VISIT/ASSESSMENT _____ MEETING DATE/TIME

SCREENED OUT REFERRED TO: _______________________

CLIENT NAME: ____________ LIKES TO BE REFERRED TO:

ADDRESS: _____ CITY/ZIP: _

PHONE: _____ E-MAIL:

5. Likes: Dislikes: _____

I ___ agree to work with on the projects listed below.

Revised Goal _:____________________________________________________

Achieved Goal _:___________________________________________________

______________________________________________________________ Achieved:

_______________________________________________________________ Achieved:

_______________________________________________________________ Achieved:

______________________________________________________________ Achieved:

_______________________________________________________________ Achieved:

_______________________________________________________________ Achieved:

Threat of Eviction: ________ Threat of Condemnation: _

Date: Client Name: Assessor: ___________________

Volunteer: _____________ Date:

Program Coordinator: _____ Date:

Volunteer: _ Client: _

Date of Visit: ___ Time Spent: _