Jino Distasio

The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities

Introduction Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city,

Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: A mixed methods approach

110 million demonstration project and provides the rationale for key scientific decisions. Methods A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project. Trial registration number This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.

A Multiple-City RCT of Housing First With Assertive Community Treatment for Homeless Canadians With Serious Mental Illness

This research sought to determine whether the implementation of Housing First in a large-scale, multi-site Canadian project for homeless participants with mental illness shows high fidelity to the Pathways Housing First model, and what factors help or hinder implementation. Fidelity ratings for 10 Housing First programs in five cities were made by an external quality assurance team along five key dimensions of Housing First based on 84 key informant interviews, 10 consumer focus groups, and 100 chart reviews. An additional 72 key informant interviews and 35 focus groups yielded qualitative data on factors that helped or hindered implementation. Overall, the findings show a high degree of fidelity to the model with more than 71% of the fidelity items being scored higher than 3 on a 4-point scale. The qualitative research found that both delivery system factors, including community and organizational capacity, and support system factors, training and technical assistance, facilitated implementation. Fidelity challenges include the availability of housing, consumer representation in program operations, and limitations to the array of services offered. Factors that accounted for these challenges include low vacancy rates, challenges of involving recently homeless people in program operations, and a lack of services in some of the communities. The study demonstrates how the combined use of fidelity assessment and qualitative methods can be used in implementation evaluation to develop and improve a program.

Relationship Between Adverse Childhood Experiences and Homelessness and the Impact of Axis I and II Disorders

OBJECTIVE Housing First with assertive community treatment (ACT) is a promising approach to assist people with serious mental illness to exit homelessness. The article presents two-year findings from a multisite trial on the effectiveness of Housing First with ACT. METHODS The study design was a randomized controlled trial conducted in five Canadian cities. A sample of 950 participants with serious mental illness who were absolutely homeless or precariously housed were randomly assigned to receive either Housing First with ACT (N=469) or treatment as usual (N=481). RESULTS Housing First participants spent more time in stable housing than participants in treatment as usual (71% versus 29%, adjusted absolute difference [AAD]=42%, p<.01). Compared with treatment-as-usual participants, Housing First participants who entered housing did so more quickly (73 versus 220 days, AAD=146.4, p<.001), had longer housing tenures at the study end-point (281 versus 115 days, AAD=161.8, p<.01), and rated the quality of their housing more positively (adjusted standardized mean difference [ASMD]=.17, p<.01). Housing First participants reported higher quality of life (ASMD=.15, p<.01) and were assessed as having better community functioning (ASMD=.18, p<.01) over the two-year period. Housing First participants showed significantly greater gains in community functioning and quality of life in the first year; however, differences between the two groups were attenuated by the end of the second year. CONCLUSIONS Housing First with ACT is an effective approach in various contexts for assisting individuals with serious mental illness to rapidly exit homelessness.

Further Validation of the Pathways Housing First Fidelity Scale

OBJECTIVES We investigated the links between homelessness associated with serious mental and physical healthy disparities and adverse childhood experiences (ACEs) in nationally representative data, with Axis I and II disorders as potential mediators. METHODS We examined data from the National Epidemiologic Survey of Alcohol and Related Conditions in 2001-2002 and 2004-2005, and included 34,653 participants representative of the noninstitutionalized US population who were 20 years old or older. We studied the variables related to 4 classes of Axis I disorders, all 10 Axis II personality disorders, a wide range of ACEs, and a lifetime history of homelessness. RESULTS Analyses revealed high prevalences of each ACE in individuals experiencing lifetime homelessness (17%-60%). A mediation model with Axis I and II disorders determined that childhood adversities were significantly related to homelessness through direct effects (adjusted odd ratios = 2.04, 4.24) and indirect effects, indicating partial mediation. Population attributable fractions were also reported. CONCLUSIONS Although Axis I and II disorders partially mediated the relationship between ACEs and homelessness, a strong direct association remained. This novel finding has implications for interventions and policy. Additional research is needed to understand relevant causal pathways.

A history in-care predicts unique characteristics in a homeless population with mental illness.

OBJECTIVE This study examined whether Housing First fidelity ratings correspond to program operation descriptions from administrative data and predict client outcomes. METHODS A multisite, randomized controlled trial (At Home/Chez Soi) in five Canadian cities included two assessments of 12 programs over two years. Outcomes for 1,158 clients were measured every six months. Associations between fidelity ratings and administrative data (Spearman correlations) and participant outcomes (mixed-effects modeling) were examined. RESULTS Fidelity ratings were generally good (mean ± SD=136.6 ± 10.3 out of a possible range of 38-152; 87% of maximum value). Fidelity was significantly associated with three of four measures of program operation, with correlations between .55 and .60. Greater program fidelity was associated with improvement in housing stability, community functioning, and quality of life. CONCLUSIONS Variation in program fidelity was associated with operations and outcomes, supporting scale validity and intervention effectiveness. These findings reinforced the value of using fidelity monitoring to conduct quality assurance and technical assistance activities.

Tenants with additional needs: when housing first does not solve homelessness

Multiple studies of homeless persons report an increased prevalence of a history in-care, but there is a dearth of information on associated outcomes or relevant demographic profiles. This information is critical to understanding if certain individuals are at elevated risk or might benefit from specific intervention. Here, we investigate how a history in-care relates to demographics and multiple outcome measures in a homeless population with mental illness. Using the Mini International Neuropsychiatric Interview (MINI), the Short-Form 12, and a trauma questionnaire, we investigated baseline differences in demographics and length of homelessness in the At Home/Chez Soi Trial (N=504) Winnipeg homeless population with and without a history in-care. Approximately 50% of the homeless sample reported a history in-care. This group was significantly more likely to be young, female, married or cohabitating, of Aboriginal heritage, have less education, and have longer lifetime homelessness. Individuals of Aboriginal heritage with a history in-care were significantly more likely to report a familial history of residential school. Individuals with a history in-care experienced different prevalence rates of Axis 1 mental disorders. Those with a history in-care also reported significantly more traumatic events (particularly interpersonal). A distinctive high-risk profile emerged for individuals with a history in-care. Sociocultural factors of colonization and intergenerational transmission of trauma appear to be particularly relevant in the trajectories for individuals of Aboriginal heritage. Given the high prevalence of a history in-care, interventions and policy should reflect the specific vulnerability of this population, particularly in regards to trauma-informed services.

Employment and Income of People Who Experience Mental Illness and Homelessness in a Large Canadian Sample.

Abstract Background: At Home/Chez-Soi was a 24 month randomized controlled trial of Housing First (HF) conducted in five Canadian cities. Aims: This article attempts to identify the characteristics of participants who experienced housing instability one year after entering HF. Methods: Those defined as experiencing housing instability were housed <50% of the last 9 months of the first year, excluding time in institutions, unless they were housed 100% of the past 3 months. Results: Only 13.5% of HF participants (n = 157/1162) met criteria for housing instability. Several variables were significant predictors of instability in between-group comparisons and multiple regression analyses: residence in Winnipeg, cumulative lifetime homelessness, percent of previous 3 months spent in jail, and community psychological integration; while residence in Moncton and a diagnosis of PTSD or panic disorder predicted stability. The predictive models were weak, identifying correctly only 3.8% of individuals that failed to achieve housing stability. Conclusions: It is not possible to predict confidently at baseline who will experience early housing instability in HF. There are certain individual characteristics that might be considered risk factors. Providing HF to all individuals who qualify for a HF program remains the most valid way to administer admission to housing.

Effects of Housing First on Employment and Income of Homeless Individuals: Results of a Randomized Trial

Objectives: Research suggests that homeless people with mental illness may have difficulty obtaining employment and disability benefits. Our study provides a comprehensive description of sources of income and employment rates in a large Canadian sample. Methods: Participants (n = 2085) from the 5 sites of the At Home/Chez Soi study were asked about their income, employment, and desire for work during the pre-baseline period. The proportion of participants employed, receiving government support, and relying on income from other activities were compared across sites, as were total income and income from different sources. Generalized linear models were used to identify participant characteristics associated with total income. Results: Unemployment ranged from 93% to 98% across 5 sites. The per cent of participants who wanted to work ranged from 61% to 83%. Participants relied predominantly on government assistance, with 29.5% relying exclusively on welfare, and 46.2% receiving disability benefits. Twenty-eight per cent of participants received neither social assistance nor disability income. Among the 2085 participants, 6.8% reported income from panhandling, 2.1% from sex trade, and 1.2% from selling drugs. Regression models showed that income differed significantly among sites and age groups, and was significantly lower for people with psychotic illnesses. Conclusion: These results suggest that homeless people with mental illness are predominantly unemployed, despite expressing a desire to work. In Canada, this group relies predominantly on welfare, but has access to disability benefits and employment insurance. These findings highlight the importance of developing effective interventions to support employment goals and facilitate access to benefits.

Costs of services for homeless people with mental illness in 5 Canadian cities: a large prospective follow-up study

OBJECTIVE Housing First is emerging as an evidence-based practice for housing and supporting people who are homeless and have a mental illness. The objective of this study was to determine whether Housing First increases the odds of obtaining competitive employment in this population and affects income, including income from informal and illegal sources. METHODS A total of 2,148 people with a mental illness were recruited from five Canadian cities while they were homeless, classified as having moderate or high needs, and randomly assigned to Housing First or usual care. Housing First participants with high needs received assertive community treatment (ACT), and those with moderate needs received intensive case management (ICM). Every three months, participants were interviewed about employment and earnings in the previous months (median follow-up=745 days). Regression models were estimated via generalized estimating equations. RESULTS ICM recipients had lower odds of obtaining employment compared with the control group with moderate needs. The odds of obtaining employment among ICM recipients increased but their employment rate never exceeded that of the control group. For ACT recipients, the odds of obtaining employment were not significantly different from those of the control group. Among Housing First participants, persons employed at baseline, men, and younger participants had greater odds of employment compared with control participants. Housing First did not appear to significantly increase income. CONCLUSIONS This was the first large-scale randomized controlled study of Housing Firsts effects on employment. Further research is needed to determine how Housing First may be enhanced to increase odds of obtaining employment.