HOMELESSNESS PARTNERING STRATEGYNATIONAL TELEFORUM SERIES

At Home/Chez Soi

Monday, May 30th 2011,

11:30 to 1:00 p.m. (Ottawa time)

At Home/Chez Soi Overview Presentation for the Homelessness

Partnering SecretariatMonday May 30, 2011

Jayne Barker, PhD, VP, Research InitiativesCameron Keller, MC, Director, At Home/Chez Soi

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

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.

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

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

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.

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

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.

4 Essential Elements of Housing First

1. Consumer Choice2. Separation of Housing and Services3. Recovery Orientation4. Community Integration

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

Assertive Community Treatment

1:10 staff to client ratioServices and crisis coverage available 24 hours, 7 days per weekSpecialized 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 assistantMobile 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

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

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

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?

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...

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

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?

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

Consumer Involvement Con’t

From the perspective of our consumer panel – what are the highlights?Employment is central to the recovery modelPeers want to be considered and viewed as productivePeer 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.

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

Early Findings - 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

Early Findings - Quantitative cont’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

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

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

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

HOMELESSNESS PARTNERING STRATEGYNATIONAL TELEFORUM SERIES

At Home/Chez Soi

Monday, May 30th 2011,

11:30 to 1:00 p.m. (Ottawa time)