Myra Piat

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

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.

The Development of Recovery Competencies for In-patient Mental Health Providers Working with People with Serious Mental Illness

Delivering recovery-oriented services is particularly challenging in in-patient settings. The purpose of this study was to identify the most salient recovery competencies required of in-patient providers. Established methods for the development of competencies were used. Data collection included interviews with multiple stakeholders and a literature review. Data analysis focused on understanding how characteristics of the in-patient context influence recovery-enabling service delivery and the competencies associated with addressing these issues. Eight core competencies with four to ten sub-competencies were identified based on a tension–practice–consequence model. The competency framework can serve as a tool for tailoring workforce education.

The Transformation of Mental Health Services To a Recovery-Orientated System of Care: Canadian Decision Maker Perspectives

Background: Recovery is emerging as a worldwide paradigm in mental health. There is increasing recognition that the transformation of mental health systems to a recovery perspective requires collaboration among all stakeholders. Research to date has focused on the perspectives of service users and providers. The role and influence of organizational decision makers in the transformation process has been less studied. Materials: This study reports findings from semi-structured interviews with decision makers on the implementation of recovery in Canada. Discussion: Decision makers view community-based services as most open to recovery-based approaches, and front-line providers as pivotal in implementing system change. Decision makers described their own role as limited to providing overall orientation and funding. Conclusions: The shift to recovery must include active leadership from decision makers as a catalyst to change.

Planning a Multi-site, Complex Intervention for Homeless People with Mental Illness: The Relationships Between the National Team and Local Sites in Canada’s At Home/Chez Soi Project

This research focused on the relationships between a national team and five project sites across Canada in planning a complex, community intervention for homeless people with mental illness called At Home/Chez Soi, which is based on the Housing First model. The research addressed two questions: (a) what are the challenges in planning? and (b) what factors that helped or hindered moving project planning forward? Using qualitative methods, 149 national, provincial, and local stakeholders participated in key informant or focus group interviews. We found that planning entails not only intervention and research tasks, but also relational processes that occur within an ecology of time, local context, and values. More specifically, the relationships between the national team and the project sites can be conceptualized as a collaborative process in which national and local partners bring different agendas to the planning process and must therefore listen to, negotiate, discuss, and compromise with one another. A collaborative process that involves power-sharing and having project coordinators at each site helped to bridge the differences between these two stakeholder groups, to find common ground, and to accomplish planning tasks within a compressed time frame. While local context and culture pushed towards unique adaptations of Housing First, the principles of the Housing First model provided a foundation for a common approach across sites and interventions. The implications of the findings for future planning and research of multi-site, complex, community interventions are noted.

An Application of Theory-Driven Evaluation to a Drop-In Youth Center

This article reports on the theory-driven evaluation of a drop-in center for youth that incorporated a literature search, concept mapping with staff, and focus groups with youth. Findings revealed strong agreement among the three sources of data around specific elements identified as critical components of a program theory of global prevention in after-school-hours initiatives, such as drop-in centers. These results are used to illustrate how a theory-driven approach was relevant for the context and objectives of this evaluation, as well as how it was used to develop knowledge useful for action, social intervention theory, and further research.

Implementing Housing First Across Sites and Over Time: Later Fidelity and Implementation Evaluation of a Pan-Canadian Multi-site Housing First Program for Homeless People with Mental Illness.

Abstract This article examines later fidelity and implementation of a five-site pan-Canadian Housing First research demonstration project. The average fidelity score across five Housing First domains and 10 programs was high in the first year of operation (3.47/4) and higher in the third year of operation (3.62/4). Qualitative interviews (36 key informant interviews and 17 focus groups) revealed that staff expertise, partnerships with other services, and leadership facilitated implementation, while staff turnover, rehousing participants, participant isolation, and limited vocational/educational supports impeded implementation. The findings shed light on important implementation “drivers” at the staff, program, and community levels.

Participant Perspectives on Housing First and Recovery: Early Findings From the At Home/Chez Soi Project

OBJECTIVE This study presents early qualitative findings from participant narratives collected for At Home/Chez Soi, a pan-Canadian demonstration project evaluating the Housing First approach. The aim of the study was to better understand how receiving housing prior to treatment impacts engagement and envisioned recovery for previously homeless individuals with mental illness. METHOD Semistructured interviews were conducted with recently housed participants within the five research sites (N = 27). An analysis of early findings was performed, and themes were identified using the constant comparative method. RESULTS Most participants reported that housing represents an early step in rebuilding identity, which enabled them to envision a different future. A subgroup experienced demoralization related to personal challenges, and expressed concerns about adjustment issues and social isolation. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE By providing choice regarding housing, Housing First facilitates a sense of personhood, which is essential to recovery. However, some recently housed individuals with complex needs may require additional supports to address early adjustment issues. (

Life Changes Among Homeless Persons With Mental Illness: A Longitudinal Study of Housing First and Usual Treatment

OBJECTIVE This study compared the life changes of homeless people with mental illness participating in Housing First or treatment as usual and examined factors related to various changes. METHODS Semistructured narrative interviews were conducted with 219 participants in five Canadian cities at baseline; 197 were interviewed again at 18 months after random assignment to Housing First (N=119) or treatment as usual (N=78). Interviews were coded across 13 life domains, and each participant was categorized as reporting positive, mixed-neutral, or negative changes. Housing First and treatment as usual participants were compared with respect to change patterns. Thematic analysis was used to examine factors related to various changes. RESULTS The percentage of participants in Housing First reporting positive changes was more than double that for participants in treatment as usual, and treatment as usual participants were four times more likely than Housing First participants to report negative changes. Factors related to positive changes included having stable good-quality housing, increased control over substance use, positive relationships and social support, and valued social roles. Factors related to negative changes included precarious housing, negative social contacts, isolation, heavy substance use, and hopelessness. Factors related to mixed-neutral changes were similar to those for participants reporting negative changes but were less intense. CONCLUSIONS Housing First with intensive support was related to more positive changes among homeless adults with mental illness across five Canadian cities. Those with poor housing or support, more common in treatment as usual, continued to struggle. These findings are relevant for services and social change to benefit this population.

How does Housing First catalyze recovery?: Qualitative findings from a Canadian multi-site randomized controlled trial

ABSTRACT Qualitative narrative interviews were conducted with 195 participants with histories of homelessness and mental illness at baseline and at an 18-month follow-up. Participants were randomly assigned at baseline to Housing First (HF; n = 119) or treatment as usual (TAU; n = 76) in five Canadian cities. Changes in consumers’ narratives over time were examined for 13 life domains (e.g., housing stability, typical day, social relationships). HF participants showed superior housing stability that led to three important transitions in their recovery journeys: (1) the transition from street to home (e.g., greater control over one’s environment, becoming unstuck), (2) the transition from home to community (e.g., pursuing relationships, participating in the community), and (3) the transition from the present to the future (e.g., developing autonomy and hope). In spite of the gains experienced by many HF participants and some TAU participants, there was a subgroup of HF participants and many more TAU participants who experienced considerable difficulty making positive transitions. This research affirms the importance of housing and support for people with mental illness who are homeless but extends previous research by elucidating how HF enables participants to navigate important transitions in their recovery journeys. Once housing stability is achieved, other services (e.g., supported employment, education, and socialization) are needed to accelerate the transitions that participants strive to make in their lives.

Adequacy of Help Received Among Individuals With Severe Mental Disorders

Using multiple linear regression analyses and a new assessment measure, this exploratory study identifies variables associated with help adequacy of 352 individuals with severe mental disorder. Help adequacy is higher with tobacco use, psychological distress domain, having a caregiver, help form services, being older, and lower with number of needs; accommodation, food, childcare and involvement in treatment decisions domains; number of suicide attempts, legal problems in previous year, and drugs problem. Results confirm the importance of a better collaboration with relatives, healthcare and social service providers to provide more adequate and satisfactory services for severe mental disorders individuals.