At Home/Chez Soi: Addressing Homelessness through Partnering and Strategy

1. HOMELESSNESS PARTNERING STRATEGYNATIONAL TELEFORUM SERIESAt Home/Chez Soi Monday, May 30th 2011, 11:30 to 1:00 p.m. (Ottawa time)

2. At Home/Chez Soi Overview Presentation for the Homelessness Partnering Secretariat Monday May 30, 2011 Jayne Barker, PhD, VP, Research Initiatives Cameron Keller, MC, Director, At Home/Chez Soi

3. At Home/Chez Soi Overview In 2008 the Federal government allocated $110 million to the Mental Health Commission of Canada to undertake At Home/Chez Soi, a 5-year research demonstration project At Home/Chez Soi is: • the largest study of its kind in the world • providing evidence about what services and systems best help people experiencing serious mental health issues and homelessness; • based on the Housing First model • a collaborative project committed to involving people with lived experience throughout the project • implemented in: Vancouver, Winnipeg, Toronto, Montreal, Moncton • Funding – 85% services / 15% research

4. At Home/Chez Soi Project Principles • People with lived experience are central • Development of a knowledge-base with respect to the homeless mentally ill that will ultimately support more effective interventions • Build on related work to maximize scope of the results and impact of the study • Research ethically sound • Support knowledge exchange • Foster collaborations and partnerships to avoid duplication of efforts and to leverage funds • Work with communities to ensure lasting results and buy-in • Strive for long-term improvements in the quality of life of participants • Address fragmentation through improved system integration.

5. At Home/Chez Soi Outcomes • Development of an accessible knowledge-base • Effective approaches to integrating housing supports and the Basket of Necessary Services • Development of Best Practices and Lessons Learned • Data that reflects impact and prevalence of mental health issues amongst homeless population • Data that reflects regional and subset population distinctions and barriers • Identification of unique problems and solutions for diverse ethno-cultural groups • Legacy of improved system integration and support

6. At Home/Chez Soi Research Design • Pragmatic, multi-site field trial of the effectiveness and costs of a complex community intervention using mixed methods • Randomizing participants into experimental and control conditions • Definition of the target group and the nature of the experimental condition common across the sites • Comparisons to care as usual in all cities

7. Data Collection • Client data is being collected at baseline and then every six months for the following two years. • Qualitative research and evaluation focusing on: • planning and proposal development phase; • personal stories of consumers at baseline; • implementation of the intervention; and, • personal stories of consumers at the 18-month follow-up.

8. At Home/Chez Soi Eligibility Criteria for inclusion in the project are: • Legal adult status (aged 18 or older) • Meets definition of homelessness • The presence of any serious mental health issues If randomized to an intervention group, participant must: • Agree to weekly visit • Contribute up to 30% of income towards rent

9. What is Housing First? Housing First is a program that provides immediate access to permanent housing and support services with a philosophy of consumer choice. Consumers are not required to participate in psychiatric treatment or attain a period of sobriety in order to obtain housing.

10. 4 Essential Elements of Housing First 1. Consumer Choice 2. Separation of Housing and Services 3. Recovery Orientation 4. Community Integration

11. Intensive Case Management • 1:20 staff to client ratio • Intensive case managers are responsible for coordinating services • Service available 7 days per week, a minimum of 12 hours per day • Familiarity with case loads of others on the team necessary for bridging during non-service hours • Brokers access to all necessary services including psychiatry, primary health care and other community services • Embraces a recovery-orientation • Creates a participant-centered pathway to independent living, or at a minimum, living with greater independence • Individualized goal setting and case planning

12. Assertive Community Treatment • 1:10 staff to client ratio • Services and crisis coverage available 24 hours, 7 days per week • Specialized transdisciplinary unit that includes Team Leader • Includes social workers, employment specialists, substance abuse specialists, psychiatrist, nurse, peer specialists, wellness specialists, family systems specialist and administrative assistant • Mobile and provides direct support in community • Provides a platform for implementing effective practices: • Family education, supported employment, integrated mental health and substance abuse treatment, peer support, motivational interviewing, psychotherapy practices, wellness management recovery

13. Thorny Issues • Randomization issues • Involving consumers in all aspects of the project • Landlord/tenant issues • Recruitment rates/project timelines • Interface between research and service • Managing critical incidents i.e. client deaths/suicide • Keeping participants engaged i.e. discharge a last resort • Sustainability/transition planning • Breaking down silos in service systems • Ethical challenges/dilemmas

14. Randomization of treatment as usual • Difficulty for participants randomized to TAU • Ethics considerations – keep the “big picture” in mind • Help participants understand process and manage expectations of both participants and referring sources • Referring parties must not see At Home/Chez Soi as a crisis intervention plan • Providing links to existing services for TAU • Support for front line interviewers – debriefing

15. Landlord/tenant issues • Stigma and “NIMBY-ism” • Information sharing/disclosure • Apartment damage/insurance • Substance misuse • If you were a landlord, what would your concerns be if you were approached by At Home/Chez Soi? • What strategies could we use to engage landlords effectively?

16. Various Ethical Challenges • Information sharing/privacy • Relationships and boundaries • Ethics of continuing the study if results demonstrate effectiveness before the end of the trial • Danger, aggression and violence • Cultural safety • Others...

17. Keeping participants engaged • Two conditions to Housing First • Pay up to 30% of income towards rent/lease • Agree to a weekly visit • What if a project participant refuses to agree to a visit? • When do you discharge from a Housing First program? • How Housing First differs from traditional approaches i.e. “stickwithitness” and client choice

18. Recruitment challenges • Referrals – getting adequate numbers and quality of referrals • Ensuring eligibility criteria applied evenly across sites • Seasonal effects • Impacts on research and service teams as pace of recruitment changes over time • Why might some referral sources not want to refer to the At Home/Chez Soi project? • Why might a project participant decide she/he is not interested in being a participant, even if determined eligible?

19. Consumer Involvement • Consumers/survivors as a social movement • Origins of the consumer/survivor movement – started in Vancouver with Mental Patients Association Society (MPA) in 1971 • Consumer Research Consultant • National consumer panel • Persons with lived experience (PWLE) and families involved in Local Advisory Committees and service and research teams • Examples of contributions of NCP • Use of measures • Qualitative interviews • Media involvement • Stigma • Hiring, support and accommodation • National Film Board documentary

20. Consumer Involvement Con’t • From the perspective of our consumer panel – what are the highlights? • Employment is central to the recovery model • Peers want to be considered and viewed as productive • Peer positions provide learning experiences for the peers themselves • What about you? • Many of you have either lived experience of mental illness yourself or through a family member or friend – you have siblings, friends, etc.

21. At Home/Chez Soi Early Findings • Project results so far – may change over time • Based on partial sample – differences across sites do not necessarily reflect difference in homeless populations • Housing First group only – no comparisons to TAU group will be released until 12-month data analyzed • Early findings reports to be released every few months as project continues • First report in DRAFT form – not yet released

22. EarlyFindings - Quantitative • Based on first 75% recruited • Primarily middle-aged, with 1 in 10 being under 25 and 1 in 10 being over 55 years of age • Typical participant is middle-aged male – shelter or streets • Most from shelters or streets • About 20% were in precarious living situations • 30% of study participants are women • Approx 1/3 had involvement with criminal justice system in last year

23. EarlyFindings - Quantitativecont’d • Significant proportion of participants have a serious mental illness. Approximately 50% would meet criteria for a psychotic diagnosis and many have problems with substance dependence • Group of participants who have non-psychotic mental health issues. They also have a lot of addiction issues and one in five have recently contemplated or attempted suicide • Intentionally, differences in ethno-cultural and First Nations make-up across cities • Other site differences include Moncton – rural homelessness and Vancouver – higher rates of psychosis and criminal justice

24. Early Findings – Qualitative Themes • Participants’ comments reflect perceptions regarding the importance of the project for allowing them to think beyond immediate survival needs and to orient toward the future • Theme of the ability to envision “getting back on track” which provides participants with motivation to make necessary life changes to achieve their goals • Theme of profound demoralization and “never feeling better” despite housing and services • Theme of housing as an opportunity for independence, safety and belonging – but partly counteracted by reports of isolation and greater risk in some cases

25. Early Findings - Qualitative Themes cont’d • Theme of the project providing an opportunity to establish new connections and community • Theme of appreciation for the project’s support – but why not sooner? • Theme of project as a turning point in life

26. Making a difference Since the implementation of At Home/Chez Soi : • hundreds of Canadian who were homeless and living with mental health issues, are now housed and receiving supports • we are beginning to learn about what service and system interventions best achieve housing stability and improved health and well-being • there has been significant willingness to do ‘business differently’ which is producing unique collaborations and is helping improve system integration • people with lived experience are involved in the project and are providing valuable advice and input on project implementation and design

27. HOMELESSNESS PARTNERING STRATEGYNATIONAL TELEFORUM SERIESAt Home/Chez Soi Monday, May 30th 2011, 11:30 to 1:00 p.m. (Ottawa time)