Vicky Stergiopoulos

Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness A Randomized Trial

IMPORTANCE Scattered-site housing with Intensive Case Management (ICM) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment. OBJECTIVE To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services. DESIGN, SETTING, AND PARTICIPANTS The At Home/Chez Soi project was an unblinded, randomized trial. From October 2009 to July 2011, participants (N = 1198) were recruited in 4 Canadian cities (Vancouver, Winnipeg, Toronto, and Montreal), randomized to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months. INTERVENTIONS The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities. MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of days stably housed during the 24-month period following randomization. The secondary outcome was generic quality of life, assessed by a EuroQoL 5 Dimensions (EQ-5D) health questionnaire. RESULTS During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites. [table: see text] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group (60.5 [95%CI, 58.6 to 62.5] at baseline and 67.2 [95%CI, 65.2 to 69.1] at 24 months for the intervention group vs 62.1 [95% CI, 59.9 to 64.4] at baseline and 68.6 [95%CI, 66.3 to 71.0] at 24 months for the usual care group, difference in mean changes, 0.10 [95%CI, −2.92 to 3.13], P=.95). CONCLUSIONS AND RELEVANCE Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months, but did not improve generic quality of life. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN42520374.

Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto

BackgroundThe At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.MethodsHomeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.ResultsThe effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.ConclusionsRecruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.

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.

Old and homeless: A review and survey of older adults who use shelters in an urban setting

Objectives: Research on the mental health and service needs of homeless seniors has been scant. This paper reviews the available literature and presents findings of a Toronto survey in an effort to describe the demographics of homeless seniors, their level of impairment, and their mental and physical health needs. Methods: We searched the Medline, AgeLine, and PsycINFO databases, using the following key words: elderly homeless, elderly hostel users, and urban geriatrics. To better describe the service needs of the elderly homeless, we obtained demographic data from the Community and Neighbourhood Services Department and distributed a survey questionnaire to 11 Toronto hostel directors. The questionnaire elicited data relating to reasons for shelter use, problem behaviours, and mental health needs of those over age 65 years. Results: Although seniors represent a small percentage of the homeless population, their numbers are growing. The available literature suggests a high prevalence of psychiatric disorders and cognitive impairment in this population, with a greater proportion of older women than men having severe mental illness. Further, our survey suggests that the service needs of elderly hostel users in Toronto differ from those of their younger counterparts. Conclusion: The homeless elderly are the most vulnerable of this impoverished population. Although more research is needed to define their mental and physical health needs and ways of meeting them, their characteristics appear to be unique. Geriatric psychiatrists could play a significant role in evaluating and treating this population more comprehensively.

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

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.

Traumatic brain injury among people who are homeless: a systematic review

BackgroundHomelessness and poverty are important social problems, and reducing the prevalence of homelessness and the incidence of injury and illness among people who are homeless would have significant financial, societal, and individual implications. Recent research has identified high rates of traumatic brain injury (TBI) among this population, but to date there has not been a review of the literature on this topic. The objective of this systematic review was to review the current state of the literature on TBI and homelessness in order to identify knowledge gaps and direct future research.MethodsA systematic literature search was conducted in PsycINFO (1887–2012), Embase (1947–2012), and MEDLINE/Pubmed (1966–2012) to identify all published research studies on TBI and homelessness. Data on setting, sampling, outcome measures, and rate of TBI were extracted from these studies.ResultsEight research studies were identified. The rate of TBI among samples of persons who were homeless varied across studies, ranging from 8%-53%. Across the studies there was generally little information to adequately describe the research setting, sample sizes were small and consisted mainly of adult males, demographic information was not well described, and validated screening tools were rarely used. The methodological quality of the studies included was generally moderate and there was little information to illustrate that the studies were adequately powered or that study samples were representative of the source population. There was also an absence of qualitative studies in the literature.ConclusionsThe rate of TBI is higher among persons who are homeless as compared to the general population. Both descriptive and interventional studies of individuals who are homeless should include a psychometrically sound measure of history of TBI and related disability. Education of caregivers of persons who are at risk of becoming, or are homeless, should involve training on TBI. Dissemination of knowledge to key stakeholders such as people who are homeless, their families, and public policy makers is also advocated.

Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups

BackgroundThe literature on interventions addressing the intersection of homelessness, mental illness and race is scant. The At Home/Chez Soi research demonstration project is a pragmatic field trial investigating a Housing First intervention for homeless individuals with mental illness in five cities across Canada. A unique focus at the Toronto site has been the development and implementation of a Housing First Ethno-Racial Intensive Case Management (HF ER-ICM) arm of the trial serving 100 homeless individuals with mental illness from ethno-racial groups. The HF ER-ICM program combines the Housing First approach with an anti-racism/anti-oppression framework of practice. This paper presents the findings of an early implementation and fidelity evaluation of the HF ER-ICM program, supplemented by participant narrative interviews to inform our understanding of the HF ER-ICM program theory.MethodsDescriptive statistics are used to describe HF ER-ICM participant characteristics. Focus group interviews, key informant interviews and fidelity assessments were conducted between November 2010 and January 2011, as part of the program implementation evaluation. In-depth qualitative interviews with HF ER-ICM participants and control group members were conducted between March 2010 and June 2011. All qualitative data were analysed using grounded theory methodology.ResultsThe target population had complex health and social service needs. The HF ER-ICM program enjoyed a high degree of fidelity to principles of both anti-racism/anti-oppression practice and Housing First and comprehensively addressed the housing, health and sociocultural needs of participants. Program providers reported congruence of these philosophies of practice, and program participants valued the program and its components.ConclusionsAdapting Housing First with anti-racism/anti-oppression principles offers a promising approach to serving the diverse needs of homeless people from ethno-racial groups and strengthening the service systems developed to support them. The use of fidelity and implementation evaluations can be helpful in supporting successful adaptations of programs and services.Trial registrationCurrent Controlled Trials ISRCTN42520374

The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness

BACKGROUND There is strong evidence that Housing First interventions are effective in improving housing stability and quality of life among homeless people with mental illness and addictions. However, there is very little evidence on the effectiveness of Housing First in improving substance use-related outcomes in this population. This study uses a randomized control design to examine the effects of scatter-site Housing First on substance use outcomes in a large urban centre. METHODS Substance use outcomes were compared between a Housing First intervention and treatment as usual group in a sample of 575 individuals experiencing homelessness and mental illness, with or without a co-occurring substance use problem, in the At Home/Chez Soi trial in Toronto, Canada. Generalized linear models were used to compare study arms with respect to change in substance use outcomes over time (baseline, 6, 12, 18 and 24 month). RESULTS At 24 months, participants in the Housing First intervention had significantly greater reductions in number of days experiencing alcohol problems and amount of money spent on alcohol than participants in the Treatment as Usual group. No differences between the study arms in illicit drug outcomes were found at 24 months. CONCLUSIONS These findings show that a Housing First intervention can contribute to reductions in alcohol problems over time. However, the lack of effect of the intervention on illicit drug problems suggests that individuals experiencing homelessness, mental illness and drug problems may need additional supports to reduce use. TRIAL REGISTRATION Current controlled trials ISRCTN42520374.

Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings

BackgroundResearch on discrimination in healthcare settings has primarily focused on health implications of race-based discrimination among ethno-racial minority groups. Little is known about discrimination experiences of other marginalized populations, particularly groups facing multiple disadvantages who may be subjected to other/multiple forms of discrimination. Objectives: (1) To examine the prevalence of perceived discrimination due to homelessness/poverty, mental illness/alcohol/drug related problems, and race/ethnicity/skin color while seeking healthcare in the past year among racially diverse homeless adults with mental illness; (2) To identify whether perceiving certain types of discrimination is associated with increased likelihood of perceiving other kinds of discrimination; and (3) To examine association of these perceived discrimination experiences with socio-demographic characteristics, self-reported measures of psychiatric symptomatology and substance use, and Emergency Department utilization.MethodsWe used baseline data from the Toronto site of the At Home/Chez Soi randomized controlled trial of Housing First for homeless adults with mental illness (n = 550). Bivariate statistics and multivariable logistic regression models were used for the analysis.ResultsPerceived discrimination related to homelessness/poverty (30.4%) and mental illness/alcohol/substance use (32.5%) is prevalent among ethnically diverse homeless adults with mental illness in healthcare settings. Only 15% of the total participants reported discrimination due to race/ethnicity/skin color. After controlling for relevant confounders and presence of psychosis, all types of discrimination in healthcare settings were associated with more frequent ED use, a greater - 3 - severity of lifetime substance abuse, and mental health problems. Perceiving discrimination of one type was associated with increased likelihood of perceiving other kinds of discrimination.ConclusionsUnderstanding the experience of discrimination in healthcare settings and associated healthcare utilization is the first step towards designing policies and interventions to address health disparities among vulnerable populations. This study contributes to the knowledge base in this important area.Trial registration numberThis study has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374.

The promise of recovery: narratives of hope among homeless individuals with mental illness participating in a Housing First randomised controlled trial in Toronto, Canada

Objectives Hope is widely embraced as an important factor in the recovery process. The role of housing in inspiring hope and facilitating recovery has been explored with homeless populations but is not well understood. This study explores perspectives on hopes for recovery and the role of housing on these hopes from the perspective of homeless adults experiencing mental illness participating in a multisite Housing First randomised controlled trial in Canada. The study draws on data from in-depth qualitative interviews with participants from the Toronto, Ontario site of the ‘At Home/Chez Soi’ Project. Design In-depth interviews were conducted with a subsample of participants from a larger Housing First randomised controlled trial. Setting The research took place in Toronto, Canada. Participants 60 participants in the larger trial (36 from the Housing First group and 24 from the Treatment as Usual group) took part in in-depth interviews. Method Participants for the in-depth interviews were purposively selected from the larger trial sample in Toronto and participated in an interview at the beginning of the study (baseline). Data from the baseline interviews were analysed using the constant comparative method derived from grounded theory methods. Results Participants’ narratives show clear visualisation of goals for recovery, and emphasise that housing is an integral factor that can facilitate hope and support dimensions of recovery. However, some participants had difficulty adjusting to housing, and were concerned about feeling socially isolated, which could have negative implications for hopefulness and recovery. Conclusions Housing First interventions should explicitly incorporate hope-inspiring, recovery-oriented approaches and support participants while adjusting to housing in order to sustain hopefulness.