Navigating Complex Implementation Contexts: Overcoming Barriers and Achieving Outcomes in a National Initiative to Scale Out Housing First in Canada

Community-based social interventions for people with severe mental illness: a systematic review and narrative synthesis of recent evidence

People living with severe mental illness (SMI) are one of the most marginalized groups in society. Interventions which aim to improve their social and economic participation are of crucial importance to clinicians, policy-makers and people with SMI themselves. We conducted a systematic review of the literature on social interventions for people with SMI published since 2016 and collated our findings through narrative synthesis. We found an encouragingly large amount of research in this field, and 72 papers met our inclusion criteria. Over half reported on the effectiveness of interventions delivered at the service level (supported accommodation, education or employment), while the remainder targeted individuals directly (community participation, family interventions, peer-led/supported interventions, social skills training). We identified good evidence for the Housing First model of supported accommodation, for the Individual Placement and Support model of supported employment, and for family psychoeducation, with the caveat that a range of models are nonetheless required to meet the varied housing, employment and family-related needs of individuals. Our findings also highlighted the importance of contextual factors and the need to make local adaptations when "importing" interventions from elsewhere. We found that augmentation strategies to enhance the effectiveness of social interventions (particularly supported employment and social skills training) by addressing cognitive impairments did not lead to transferable "real life" skills despite improvements in cognitive function. We also identified an emerging evidence base for peer-led/supported interventions, recovery colleges and other interventions to support community participation. We concluded that social interventions have considerable benefits but are arguably the most complex in the mental health field, and require multi-level stakeholder commitment and investment for successful implementation.

Fatores contextuais e implantação da intervenção Housing First: uma revisão da literatura

Resumo O Housing First (HF) tem se difundido no cenário internacional como uma intervenção baseada em evidência para superar a situação de rua entre pessoas com agravos de saúde mental. No Brasil, o HF tem sido adotado como referência no desenvolvimento de iniciativas voltadas para pessoas em situação de rua que fazem uso prejudicial de drogas. Estudos apontam a necessidade de maior compreensão da dinâmica implantação do modelo HF em diferentes cenários. De tal modo, utilizando o método de revisão de literatura, analisamos os fatores que facilitam e dificultam a implantação do HF. Foram selecionados 68 artigos, publicados entre 2003 e 2020, nas bases PubMed, Scopus, PsychoINFO, Embase, Lilacs e Scielo. Identificamos fatores em quatro dimensões: características da intervenção, contexto de implantação, aspectos institucionais e processo de implantação. A indisponibilidade de habitações, a falta de coordenação dos serviços necessários aos moradores e a resistência dos agentes implantadores aos princípios do HF são fatores que dificultam a implantação. Por sua vez, agentes com valores, atitudes e competências convergentes ao modelo e educação permanente aparecem como facilitadores. Apontamos a necessidade de se compreender e favorecer o processo de integração do HF aos sistemas de proteção social existentes.

Perceived care coordination among permanent supportive housing participants: Evidence from a managed care plan in the United States

Homelessness is a pervasive public health problem in the United States (U.S.). Under the U.S. Affordable Care Act, the nation's public health insurance program (Medicaid) was expanded to serve more individuals, including those experiencing homelessness. Coupled with changes in financial incentives designed to reduce healthcare costs, health plans, hospitals and large health systems have started to operate permanent supportive housing (PSH) programmes as a healthcare benefit. To better understand patient perceptions of care coordination in a PSH programme operated by a large health plan in Southern California, we conducted 22 semi-structured in-depth patient interviews between October and November 2019. Two coders analysed these data inductively and deductively, using pre-identified domains and open coding. Coding reliability and thematic saturation were also assessed. Findings indicated positive experiences with care coordination for physical health and social supports, such as food distribution and transportation. Identified service gaps included mental health support and help securing public assistance (e.g., cash benefits). Opportunities to enhance PSH care coordination were also identified, such as the need for a simplified approach. Hospitals, health plans and systems considering PSH programmes may look to these results for implementation guidance.

Homeless Adults' Recovery Experiences in Housing First and Traditional Services Programs in Seven European Countries

Across Europe, as governments turn to housing-led strategies in attempts to reverse rising rates of homelessness, increasing numbers of Housing First (HF) programs are being implemented. As HF programs become more widespread, it is important to understand how service users experience them compared to the more prevalent traditional treatment-first approach to addressing long-term homelessness. Although there is a large body of research on service users' experiences of Housing First compared to treatment-first in North American contexts, comparatively less is known about how these two categories of homeless services are experienced in the European context. In a correlational and cross-sectional study, part of a larger examination of homelessness in Europe, participants (n = 520) engaged with either HF (n = 245) or traditional services (TS; n = 275) programs in seven countries completed measures of their experiences of services (consumer choice, housing quality, and service satisfaction) and recovery (time in independent housing, psychiatric symptoms, and community integration). Across the seven countries, participants engaged with HF programs reported experiencing more consumer choice, better perceived housing quality, and more satisfaction with services than participants engaged in TS programs. Participants in HF programs also reported a greater proportion of time in independent accommodation, fewer psychiatric symptoms, and more community integration. Varying patterns of association between experiences of services and recovery outcomes were observed. Findings indicate HF consistently predicts greater recovery than TS across diverse sociopolitical and economic contexts. Implications of findings for configurations of homeless services and homeless services policy are discussed.