Studies of "supported" and "supportive" housing: a comprehensive review of model descriptions and measurement

Promoting Sustainability in Housing with Services: Insights From the Right Care, Right Place, Right Time Program

Despite the widely-acknowledged potential of housing with services for improving the lives of low-income older adults, ensuring their financial sustainability has been challenging. This study aimed to address this issue, drawing on 31 key informant interviews and three focus groups with payers, housing providers, and community partners involved in the Boston-area Right Care, Right Place, Right Time Program, which enrolled about 400 older adults. Transcripts were qualitatively analyzed using thematic coding. Participants agreed on the program's value, but there was little consensus on mechanisms for securing ongoing funding. The broadly distributed responsibility for individuals in housing sites, which involves health insurers, hospitals, and community service providers, provides little incentive for investment by these entities. Findings suggest that governmental mechanisms, probably at the federal level, are needed to channel funding toward these supportive services. Without such reliable funding sources, replication of supportive housing models for low-income older people will prove difficult.

Permanent Supportive Housing Receipt and Health Care Use Among Adults With Disabilities

This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.

Tenant perspectives on the implementation of the community homes for opportunity: a focused ethnographic study in Southwestern Ontario

BACKGROUND

Recovery-oriented programs provide individuals with opportunities for well-being through community integration processes that enhance the degree to which individuals could live, work, and recreate in their community. The current evaluation assessed how tenants experience their home environment after the modernization of Homes for Special Care (HSC) to Community Homes for Opportunity (CHO) in Southwest Ontario, Canada. Our study identifies existing policies and practices that could interfere with or promote the modernization process.

METHODS

We applied ethnographic qualitative techniques to purposefully recruit 188 participants with severe mental illness from 28 group homes. Focus groups were conducted at three time points, i.e., at pre-implementation/Baseline/Time I - spring 2018; Transition/Time II - fall 2018, and Final/Time III - winter 2019.

RESULTS

Study findings suggest that the transition of HSC to CHO supports activities that empower tenants towards personal growth and development. Participants were largely satisfied with the support they were getting in relation to the program-related services. Tenants disclosed that their quality of life and well-being had been enhanced through participating in the program, and that their social interaction and support for each other had also improved. Most tenants demonstrated autonomy in terms of personal and financial independence. The enhanced financial support for tenants did not only improve their quality of life, but also helped to raise their purchasing power, decision making, sense of responsibility and accountability towards healthy spending of their resources. Despite tenants' good impression about the CHO, some still encountered problems and provided suggestions to further improve the program.

CONCLUSION

It is expected that a more effective and expanded CHO will lead to tenant empowerment and successful social integration.

Supportive Housing for Sexual and Gender Minority Individuals with Criminal Justice Histories: Challenges and Opportunities Identified by Providers and Clients

Sexual and gender minority (SGM) individuals experience high rates of homelessness and criminal justice system involvement, underscoring the need for supportive housing services. To explore the service needs of this population, we interviewed providers (n = 11) and clients (n = 10) from eight supportive housing organizations working with SGM populations in Los Angeles County, USA. We used the Consolidated Framework for Implementation Research to synthesize interview responses into themes (by domain and cross-cutting). Take-aways included the need for investment in systems of care for vulnerable SGM populations; the particular marginalization of Trans individuals and providers that serve them; the roles of supportive housing staff, residents, and leadership in cultivating an affirming environment; prevalence of discrimination and stigma within supportive housing programs and broader society; and the complex interrelationships among SGM identity, homelessness, and criminal justice system involvement. These findings have important implications for supportive housing services and related policy.

Permanent Supportive Housing Tenure Among a Heterogeneous Population of Adults with Disabilities

People with disabilities can face substantial barriers to living stably in community settings. Evidence shows that permanent supportive housing (PSH), which combines subsidized housing with individualized support services, can improve housing stability among subpopulations of people with disabilities, including those with behavioral health conditions. PSH has also been shown to improve some health outcomes among people with severe mental illness or substance use disorder, but effects varied by participants' program tenure. This study assessed retention in a PSH program serving a broad population of adults with disabilities and identified factors associated with program tenure. Administrative data from 2093 individuals who began participating in a North Carolina PSH program between 2015 and 2018 were analyzed. Participants' unadjusted probability of remaining in a PSH placement at specific time points was estimated, with censoring due to death or the end of the study period (July 2020). Using Cox regression, program tenure was modeled as a function of participant and PSH placement location characteristics. Participants had a 71% probability of remaining in PSH after 2 years. Older age, female gender, and non-Hispanic Black race/ethnicity were associated with lower hazard of PSH departure. Having a severe mental illness diagnosis was associated with greater departure hazard. Level of socioeconomic deprivation and rurality of the PSH placement ZIP code were not associated with departure hazard. PSH programs may be able to successfully retain a heterogeneous population of adults with disabilities, although tenure may vary by participant demographic and clinical characteristics.

The level of formal support received by people with severe mental illness living in supported accommodation and participation: A systematic review

AIM

The review aimed to identify and explore the association of level of support received by people with severe mental illness in supported accommodation and participation.

METHOD

The authors conducted a systematic search in MEDLINE, PsychINFO, PsychARTICLES, CINAHL Plus and ASSIA. Searches were restricted to articles published in English and participants aged 18 years and over with severe mental illness. Articles were included based on level of support received in mental health supported accommodation, classified according to the Simple Taxonomy for Supported Accommodation, and three factors of participation: social participation, daily living functioning and personal empowerment. Studies of in-patient settings and nursing homes were excluded. The review protocol is registered on PROSPERO (registration number: CRD42019161808).

RESULTS

Six articles were included in the review from USA, Australia, Sweden and Taiwan. Factors of participation for people living in accommodation with moderate support and accommodation with high support were explored. Data indicated an association between level of support and participation showing that people living in accommodation with moderate support had increased participation compared to people living in accommodation with high support.

CONCLUSION

This review identified an association between level of formal support and participation. People with SMI living in accommodation with medium support participated in more community occupations, more activities and had a higher level of personal empowerment than people living in accommodation with high support.

Treatment Bed Utilization Following Placement in a Foster Care Program for Veterans with Serious Mental Illness

Hospital and residential treatment bed utilization rates were measured before and after foster home placement in individuals with serious mental illness. Medical records of all Veterans consecutively enrolled in a Department of Veterans Affairs Community Residential Care (CRC) program during a 6 year period (N = 140) were reviewed retrospectively. Treatment bed days were tabulated by bed type (psychiatric hospital, inpatient detoxification, medical hospital, physical rehabilitation, and psychosocial residential treatment) for each patient during symmetric pre- and post-placement time intervals. Pre- and post-placement bed days were compared using the paired-sample t test in a naturalistic one-group pretest-posttest analytic design. Psychiatric hospital and residential treatment bed days were significantly reduced post-placement (-77.5% and -99.8%, respectively). Most patients (89.0%) had fewer psychiatric hospital bed days post-placement, and all patients with pre-placement residential treatment program bed days had fewer of those days post-placement. Longer CRC placements were associated with greater reductions in bed utilization.

Housing interventions for emerging adults experiencing homelessness: A scoping review

INTRODUCTION

This review aims to identify and synthesize literature focused on housing interventions for young adults experiencing homelessness.

METHODS

Following a five-stage approach to scoping reviews, a computerized search was conducted between February 4-8, 2019 to include peer-reviewed articles from a total of eight electronic databases: PsychINFO, Google Scholar, PubMed, Web of Science, Social Work Abstracts, Cochrane, Clinicaltrials.gov, and CINAHL. The search was limited to include literature published between January 1, 1987 and December 31, 2018. Search parameters included three domains: homelessness, housing intervention, and age.

RESULTS

Of the initial 7,344 sources identified, 29 articles met the search criteria and were included in the final sample. Housing models discussed in the reviewed literature include Permanent Supportive Housing, Transitional and Independent Housing and Living Programs, the Foyer model, Housing First, and general Supportive Housing. Housing models were discussed in the context of outcome domains including quality of life, education, employment, housing tenure, cost of intervention, systems and service use, HIV, and social network and relationships.

DISCUSSION

Housing interventions for young adults experiencing homelessness remains a relatively new intervention to combat homelessness among younger demographics. While the evidence base continues to grow, there remains a need for quality research to generate empirical evidence in this area, though studies included in this review showed promise for the development of best housing practices with this population.

Exploring factors related to supportive housing tenure and stability for people with serious mental illness

Overall, the retention of people with serious mental illness (SMI) in supportive housing is high. However, some supportive housing settings report average stays of only 15 months, and others report declines in housing retention over time. Many studies report variables associated with supportive housing stability and tenure, but there are few extensive, focused investigations on the subject. Hence, a literature review was conducted to investigate factors associated with supportive housing stability and tenure among people with SMI. The review of the included 28 papers reveals that the factors associated with supportive housing stability and tenure fell into two general categories of individual factors (including psychiatric factors and prior homelessness), and contextual factors (including program characteristics and sense of community and social support). In conclusion, further focus on contextual factors, as well as a potential reframing of individual factors as contextual, may be helpful in addressing issues related to supportive housing stability and tenure for people with SMI.

The comparative effectiveness of different models of permanent supportive housing on problematic substance use, depression, and anxiety symptoms over time

OBJECTIVES

To compare the effectiveness of different models of permanent supportive housing (PSH), housing configuration, and service provision model on substance use, depression, and anxiety symptoms among residents over time.

METHODS

Linear mixed model regression was used with 888 residents of PSH to investigate the relationship between supportive housing type, service model, and housing configuration and change in mental health and substance use at baseline, 6-, 12-, and 18-month follow-up.

RESULTS

There were few significant differences in problematic substance use, depression, or anxiety symptoms among those in different PSH types, different housing configuration models, or different service provision models. Similarly, there were no significant differences in PSH type, housing configuration, or service delivery model among those with severe mental illness (SMI), substance use disorder (SUD), or those with dual diagnoses.

CONCLUSIONS

There is little evidence that different models of PSH result in differences in mental health and substance use outcomes. Future research should consider the number of services clients receive and critical periods in PSH residency in improving mental health and substance use outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Moving On From Supportive Housing (MOSH): Development and evaluation of a transitional skill-building curriculum for providers helping residents exit homeless services

This article describes the development and evaluation of MOSH (Moving On From Supportive Housing), a transitional skill-building curriculum for providers helping residents exit homeless services to mainstream housing without embedded supports. In this evaluation, we assess the feasibility, acceptability, fit, and potential efficacy of the MOSH curriculum to improve proximal provider-level outcomes, including self-efficacy to provide MOSH-related independent living skills and supports. Homeless-services providers (N = 49) from a range of programs and settings participated in the training. Findings from focus groups and pre- and posttest surveys indicate high levels of overall satisfaction with the training. The majority of trainees perceived the training to be useful to their work and potentially useful for service recipients, felt the training would fit well within their existing day-to-day work, and said they were very likely to use MOSH skills in such work. Statistically significant improvements in self-efficacy regarding all skills but one were also found. MOSH holds promise as an intervention that can enhance provider practice and promotion of independent living skills in homeless services. Although these initial findings on MOSH are encouraging, further research will be needed to evaluate provider knowledge gains and effective use of these skills in practice.

Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness

BACKGROUND

Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations.

OBJECTIVE

To evaluate the effects of PSH on Medicaid enrollees across New Jersey.

RESEARCH DESIGN

Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement.

SUBJECTS

A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014.

RESULTS

PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC).

CONCLUSIONS

Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

The impact of health-related supports in senior housing on ambulance transfers and visits to emergency departments: The Right Care, Right Place, Right Time Project

OBJECTIVE

To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months.

DATA SOURCES/STUDY SETTING

Intervention sites included seven Boston-area buildings, with five buildings at comparable settings acting as controls. Data derive from building-level ambulance data from emergency responders; building-level Medicare claims data on emergency department utilization; and individual-level baseline assessment data from participants in the intervention (n = 353) and control (n = 208) sites.

STUDY DESIGN

We used a pre/postdifference in difference quasi-experimental design applying several analytic methods. The preintervention period was January 2016-March 2017, while the intervention period was July 2017-December 2018.

DATA COLLECTION/EXTRACTION METHODS

Emergency responders provided aggregate transfer data on a daily basis for intervention and control buildings; the Quality Improvement Organization provided quarterly aggregate data on emergency department visit rates; and assessment data came from a modified Vitalize 360 assessment and coaching tool.

PRINCIPAL FINDINGS

The study found an 18.2% statistically significant decline in ambulance transfers in intervention buildings, with greater declines in buildings that had fewer services available at baseline, compared to other intervention sites. Analysis of Medicare claims data, adjusted for the proportion of residents over 75 per building, found fewer visits to emergency departments in intervention buildings.

CONCLUSIONS

Health-related supports in senior housing sites can be effective in reducing emergency transfers and visits to emergency departments.

Placement of chronically homeless into different types of permanent supportive housing before and after a coordinated entry system: The influence of severe mental illness, substance use disorder, and dual diagnosis on housing configuration and intensity of services

AIMS

Permanent supportive housing (PSH) is designed to house people who experience chronic homelessness with one or more of the following: serious mental illness (SMI), substance use disorders (SUD) or human immunodeficiency virus. The Department of Housing and Urban Development has required major metropolitan areas to develop a coordinated entry system (CES) to prioritize access to PSH to those who need it the most. The aim of this paper is to determine whether PSH residents with SMI, SUD, or dual diagnosis were more likely to be housed after implementation of CES and were more likely to be housed in housing models with more intensive services provided.

METHODS

A cross-sectional survey with 855 residents of different PSH models.

RESULTS

Those with SMI, SUD, or dual diagnosis were not more likely to be housed using the CES but were more likely to be housed in higher intensity service programs.

CONCLUSIONS

Those with SMI are more likely to be housed in PSH with high-intensity services.

Empowering Features and Outcomes of Homeless Interventions: A Systematic Review and Narrative Synthesis

The purpose of this systematic review and narrative synthesis was to identify homeless interventions with empowering features and evaluate their effectiveness for developing the psychological empowerment of services users. To identify and evaluate intervention studies, we combined the theoretical frameworks of empowering settings and psychological empowerment (PE). Our conceptualization of PE included outcomes aligned with the intrapersonal, interactional, and behavioral components. Relational outcomes were also included and conceptualized as antecedents for PE development. After systematic searching and screening, 37 studies were included for review. Interventions with empowering features included supported housing, case management, skills and knowledge acquisition, and mutual support. Interventions that were competency-building effectively improved outcomes aligned with the intrapersonal PE component. Interventions that were collaborative and competency-building effectively improved outcomes aligned with the behavioral PE component. Weak evidence suggested that interventions with empowering features may effectively improve outcomes aligned with the interactional PE component. Interventions that promoted and developed support effectively improved relational antecedents. Findings align the empirical evidence for homeless interventions with theoretical conceptions of empowering features and processes. Findings may be applied to the design and implementation of homeless interventions to incorporate empowering features and to facilitate the development of homeless services users' PE. Highlights Empowerment theory was applied to review homeless interventions literature. Empowering homeless interventions included supported housing and mutual support, for example. Empowering interventions contributed to indicators of emotional and behavioral empowerment. Fewer empowering interventions contributed to indicators of cognitive empowerment. Service user involvement may facilitate improvements in indicators of psychological empowerment.

Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review

BACKGROUND

Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries.

METHODS

We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

FINDINGS

Our search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1·13 [95% CI 1·01-1·26]) and high support needs (RR 1·42 [1·19-1·69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8·58 days; p<0·004), whereas the effects on mental health and employment outcomes were unclear.

INTERPRETATION

Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes.

FUNDING

Inner City Health Associates.

The outcomes of individualized housing for people with disability and complex needs: a scoping review

PURPOSE

Worldwide, disability systems are moving away from congregated living towards individualized models of housing. Individualized housing aims to provide choice regarding living arrangements and the option to live in houses in the community, just like people without disability. The purpose of this scoping review was to determine what is currently known about outcomes associated with individualized housing for adults with disability and complex needs.

METHODS

Five databases were systematically searched to find studies that reported on outcomes associated with individualized housing for adults (aged 18-65 years) with disability and complex needs.

RESULTS

Individualized housing was positively associated with human rights (i.e., self-determination, choice and autonomy) outcomes. Individualized housing also demonstrated favourable outcomes in regards to domestic tasks, social relationships, challenging behaviour and mood. However, outcomes regarding adaptive behaviour, self-care, scheduled activities and safety showed no difference, or less favourable results, when compared to group homes.

CONCLUSIONS

The literature indicates that individualized housing has favourable outcomes for people with disability, particularly for human rights. Quality formal and informal supports were identified as important for positive outcomes in individualized housing. Future research should use clear and consistent terminology and longitudinal research methods to investigate individualized housing outcomes for people with disability.Implications for rehabilitationIndividualized housing models can foster self-determination, choice and autonomy for adults with disability and complex needs.Having alignment between paid and informal support is important for positive outcomes of individualized housing arrangements.A more substantial evidence base regarding individualized housing outcomes, in particular long-term outcomes, and outcomes for people with an acquired disability, is required.

Independent Housing and Support for non-homeless individuals with severe mental illness: randomised controlled trial vs. observational study - study protocol

BACKGROUND

Social inclusion is essential for an adequate rehabilitation process for people with serious mental illness (SMI). Various supported housing settings aim to promote housing competencies and social inclusion in service users. Nevertheless, there is a strong preference in service users for independent living. We aim to evaluate the effectiveness and efficiency of Independent Housing and Support (IHS) compared to institutionalised residential care settings and other treatment as usual conditions (RCS/TAU) in two cities in Switzerland.

METHODS

This is a prospective multi-centre, four-arm, non-inferiority cohort study investigating the effectiveness and efficiency of IHS and RCS/TAU for people with SMI. Effectiveness will be measured by a standardised measure of social inclusion as primary outcome as well as by measures of functioning and well-being. Efficiency will be analysed on the basis of service usage and costs associated with the different housing settings. Participants will be consecutively recruited and subsequently enrolled between April 2019 and December 2020 and assessed at baseline and after six, twelve and after 24 months. At one study site, 56 participants will be randomly assigned to one of the conditions; the other study site will be conducted as an observational study investigating 112 admitted participants.

DISCUSSION

While the UN Convention of the Rights of People with Disabilities aims to promote the opportunity to choose one's place of residence, the limited supply of alternative forms of housing does not guarantee genuine freedom of choice. Increased diversification and flexibility of housing support is essential. If IHS shows non-inferiority in terms of their effectiveness and efficiency, users should be allowed to choose their kind of housing support.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03815604, December 04, 2019.

Provider perspectives of housing programs for young adults experiencing homelessness

OBJECTIVE

Qualitative methods were used to investigate the perspectives of service providers working in Permanent Supportive Housing, Transitional Living Programs, and Rapid Rehousing for young adults who have experienced homelessness. The primary aim was to explore how housing models were designed, implemented, and the extent to which there is variability in how providers approach their work with young adults.

METHODS

Data come from 26 housing service providers purposively sampled from supportive housing providers across the United States between October 2017 and July 2018. Interview transcripts were analyzed using a comparative case summary approach, grouped by program model.

RESULTS

Three themes emerged from the qualitative analysis related to how specific housing models were developed (Stranded between systems: "No model to follow"), the strategies that providers took to support residents toward independence and self-sufficiency (Working toward independence and self-sufficiency: "No one-sized approach"), and the various roles that individual providers discussed fulfilling in their work with young adults (Shifting roles: "Whatever type of figure is needed").

DISCUSSION

While the overarching goals of supportive housing span across housing models, the methods and philosophies of service delivery differ, mirroring the programmatic structure of the model. Results point to a competing philosophies approach to housing as it delivers different philosophically oriented programming models for similar youth through Transitional Living Programs, Permanent Supportive Housing, and Rapid Rehousing models.

Supported Housing as a recovery option for long-stay patients with severe mental illness in a psychiatric hospital in South India: Learning from an innovative de-hospitalization process

Individuals with severe mental illness have long been segregated from living in communities and participating in socio- cultural life. In recent years, owing to progressive legislations and declarations (in India and globally), there has been a growing movement towards promoting social inclusion and community participation, with emphasis on the need to develop alternative and inclusive care paradigms for persons with severe mental illness. However, transitions from inpatient care to community settings is a complex process involving implications at multiple levels involving diverse stakeholders such as mental health service users, care providers, local communities and policy makers. This article studies how the transition from a hospital setting to a community-based recovery model for personals with severe mental illness can be facilitated. It reflects on the innovative process of creating a Supported Housing model in South India, where 11 MH Service users transitioned from a psychiatric ECRC to independent living facilities. Experiences in various phases of the project development, including care provider- and community level responses and feedback were scrutinised to understand the strategies that were employed in enabling the transition. Qualitative methods (including in-depth interviews and naturalistic observations) were used with residents and staff members to explore the challenges they encountered in stabilizing the model, as well as the psychosocial benefits experienced by residents in the last phase. These were complemented with a Brief Psychiatric Rating Scale (BPRS) and WHO Quality of Life scale to compare baseline and post-assessment results and an increase of quality of life. Results display a significant reduction of psychiatric symptoms in patients (p< 0.5). It also describes the challenges encountered in the current context, and strategies that were used to respond and adapt the model to address these concerns effectively. Positive behavioural and psycho-emotional changes were observed amongst the residents, significant amongst those being enhanced in their mobility and participation. The article concludes by discussing the implications of this study for the development of innovative community-based models in wider contexts.

The role of the outer setting in implementation: associations between state demographic, fiscal, and policy factors and use of evidence-based treatments in mental healthcare

Background

Despite consistent recognition of their influence, empirical study of how outer setting factors (e.g., policies, financing, stakeholder relationships) influence public systems’ investment in and adoption of evidence-based treatment (EBT) is limited. This study examined associations among unmodifiable (e.g., demographic, economic, political, structural factors) and modifiable (e.g., allocation of resources, social processes, policies, and regulations) outer setting factors and adoption of behavioral health EBT by US states.

Methods

Multilevel models examined relationships between state characteristics, an array of funding and policy variables, and state adoption of behavioral health EBTs for adults and children across years 2002–2012, using data from the National Association for State Mental Health Program Directors Research Institute and other sources.

Results

Several unmodifiable state factors, including per capita income, controlling political party, and Medicaid expansion, predicted level of state fiscal investments in EBT. By contrast, modifiable factors, such as interagency collaboration and investment in research centers, were more predictive of state policies supportive of EBT. Interestingly, level of adult EBT adoption was associated with state fiscal supports for EBT, while child EBT adoption was predicted more by supportive policies. State per capita debt and direct state operation of services (versus contracting for services) predicted both child and adult EBT adoption.

Conclusions

State-level EBT adoption and associated implementation support is associated with an interpretable array of policy, financing, and oversight factors. Such information expands our knowledge base of the role of the outer setting in implementation and may provide insight into how best to focus efforts to promote EBT for behavioral health disorders.

Studies regarding supported housing and the built environment for people with mental health problems: A mixed-methods literature review

Places where people live are important for their personal and social lives. This is also the case for people with mental health problems living in supported housing. To summarise the existing knowledge, we conducted a systematic review of 13 studies with different methodologies regarding the built environment in supported housing and examined their findings in a thematic analysis. The built environment of supported housing involves three important and interrelated themes: well-being, social identity and privacy. If overregulated by professionals or located in problematic neighbourhoods or buildings, the settings could be an obstacle to recovery. If understood as meaningful places with scope for control by the tenants or with amenities nearby, the settings could aid recovery.

Models of Housing in the Quebec Setting for Individuals With Mental Illness

The World Health Organization (WHO) defines mental health as "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community". A person's mental health is shaped by various social, economic, physical, and environmental factors, at different stages of life. Risk factors are heavily associated with social inequalities in the domains of employment, housing, and education. Theories of social determinants of health postulate the beneficial effects of factors exterior to medicine (regarding income, housing, education, and employment) on the health of individuals and populations. Recognition of the effect of social determinants on the health of vulnerable populations has been at the core of the intervention models and housing services developed by social service professionals in Québec. This article offers a review of housing services provided to psychiatric patients living in the community, over the last 50 years in Quebec. Different models of housing with social support which contribute to the autonomy, the security, and the empowerment of psychiatric patients are presented.

From Residential Care to Supportive Housing for People With Psychiatric Disabilities: Past, Present, and Future

For centuries, treatment and accommodation for people with significant mental health conditions in many countries, including the United States, have been viewed as necessarily inseparable elements, first in asylums and then, with deinstitutionalization, in community care models. The advent of psychiatric rehabilitation and later, recovery, helped to shift the paradigm of mental health services and the role of housing, to one focused on promoting the ability of individuals to achieve not only a life located in the community, but one that reflects a meaningful life as part of a community. In this context, supportive housing emerged as a model based on integrated, permanent, affordable housing, selected by the person, with flexible supports that are functionally separate, but available as needed and wanted. This model of housing has been predominant in American mental health services for over 20 years, and evidence now exists for its outcomes in terms of housing stability, symptom reduction, and psychosocial variables. Current challenges, both at the societal and the individual level, confront the sustainability of supportive housing, with some efforts being made by housing groups to address these challenges. This article reviews the evolution of supportive housing and its basic tenets, identifying the challenges and some efforts to address them. In addition, the article discusses the current social and economic climate, which appears to be shaping opposing trends, and makes a call to action, to mitigate the possible risks to the future of this value-based housing approach.

A Review of the Literature on LGBTQ Adults Who Experience Homelessness

Little is known about lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults who experience homelessness. The current review critically analyzes the scant literature on LGBTQ adults who experience homelessness, with a particular focus on: (1) pathways into homelessness; (2) support needs; (3) targeted programming; and (4) exits out of homelessness. A total of 143 articles were identified, and 16 articles met the criteria of appropriate age range, article quality, and relevance of topic. Results from this review demonstrate that homeless LGBTQ adults have unique physical and mental health challenges, largely concerning HIV and substance use. Transgender and gender non-conforming adults who experience homelessness encounter several challenges in the homelessness system, particularly in regard to safety and gender-affirming supports. Recommendations focus on practical implications for support and suggestions for future research.

Cost Analysis of a High Support Housing Initiative for Persons with Severe Mental Illness and Long-Term Psychiatric Hospitalization

OBJECTIVE

The objective of this article was to conduct a cost analysis comparing the costs of a supportive housing intervention to inpatient care for clients with severe mental illness who were designated alternative-level care while inpatient at the Centre for Addiction and Mental Health in Toronto. The intervention, called the High Support Housing Initiative, was implemented in 2013 through a collaboration between 15 agencies in the Toronto area.

METHOD

The perspective of this cost analysis was that of the Ontario Ministry of Health and Long-Term Care. We compared the cost of inpatient mental health care to high-support housing. Cost data were derived from a variety of sources, including health administrative data, expenditures reported by housing providers, and document analysis.

RESULTS

The High Support Housing Initiative was cost saving relative to inpatient care. The average cost savings per diem were between $140 and $160. This amounts to an annual cost savings of approximately $51,000 to $58,000. When tested through sensitivity analysis, the intervention remained cost saving in most scenarios; however, the result was highly sensitive to health system costs for clients of the High Support Housing Initiative program.

CONCLUSIONS

This study suggests the High Support Housing Initiative is potentially cost saving relative to inpatient hospitalization at the Centre for Addiction and Mental Health.

Supported housing for adults with psychiatric disabilities: How tenants confront the problem of loneliness

The objective of this study was to examine the experience of loneliness among people with psychiatric disabilities after moving from custodial housing, including group homes, boarding homes, and family-type residences to independent, supported apartments in the community. Qualitative research methods guided by a naturalistic/constructivist framework were used. Data collection occurred between May 2014 and July 2015 and consisted of individual semi-structured interviews with 24 tenants residing in five supported housing sites across three Canadian provinces; interviews were also conducted with a designated family member for each tenant and with their service providers. Group interviews were conducted with housing workers in the five housing sites. The interviews were transcribed verbatim, codes generated and a thematic analysis undertaken using a constructivist approach. Results showed that for most tenants living in independent apartments with support loneliness was not a serious problem or was an issue that could be overcome. Most study participants viewed supported housing as preferable to custodial housing and as a normalising experience that facilitated community integration. While housing conditions, particularly those associated with congregate housing, sometimes helped attenuate loneliness among tenants, managing loneliness was primarily contingent on the ability of individuals to develop and maintain social connections, as well as on family involvement.

Effectiveness of interventions to reduce homelessness: a systematic review and meta-analysis

This Campbell systematic review examines the effectiveness of interventions to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming homeless. Forty-three studies were included in the review, 37 of which are from the USA. Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are: High intensity case managementHousing FirstCritical time interventionAbstinence-contingent housingNon-abstinence-contingent housing with high intensity case managementHousing vouchersResidential treatment These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.

Plain Language Summary

Interventions to reduce homelessness and improve housing stability are effective: There are large numbers of homeless people around the world. Interventions to address homelessness seem to be effective, though better quality evidence is required.What is this review about?: There are large numbers of homeless people around the world. Recent estimates are over 500,000 people in the USA, 100,000 in Australia and 30,000 in Sweden. Efforts to combat homelessness have been made on national levels as well as at local government levels.This review assesses the effectiveness of interventions combining housing and case management as a means to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming homeless.What studies are included?: Included studies were randomized controlled trials of interventions for individuals who were already, or at-risk of becoming, homeless, and which measured impact on homelessness or housing stability with follow-up of at least one year.A total of 43 studies were included. The majority of the studies (37) were conducted in the United States, with three from the United Kingdom and one each from Australia, Canada, and Denmark.What are the main findings of this review?: Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are: High intensity case managementHousing FirstCritical time interventionAbstinence-contingent housingNon-abstinence-contingent housing with high intensity case managementHousing vouchersResidential treatment These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.What do the findings of this review mean?: A range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services.However, there is uncertainty in this finding as most the studies have risk of bias due to poor reporting, lack of blinding, or poor randomization or allocation concealment of participants. In addition to the general need for better conducted and reported studies, there are specific gaps in the research with respect to: 1) disadvantaged youth; 2) abstinence-contingent housing with case management or day treatment; 3) non-abstinence contingent housing comparing group vs independent living; 4) Housing First compared to interventions other than usual services, and; 5) studies outside of the USA.How up-to-date is this review?: The review authors searched for studies published up to January 2016. This Campbell systematic review was published in February 2018.

Executive summary

Background: The United Nations Universal Declaration of Human Rights (Article 25) states that everyone has a right to housing. However, this right is far from being realized for many people worldwide. According to the United Nations High Commissioner for Refugees (UNHCR), there are approximately 100 million homeless people worldwide. The aim of this report is to contribute evidence to inform future decision making and practice for preventing and reducing homelessness.Objectives: To identify, appraise and summarize the evidence on the effectiveness of housing programs and case management to improve housing stability and reduce homelessness among people who are homeless or at-risk of becoming homeless.Search methods: We conducted a systematic review in accordance with the Norwegian Knowledge Centre's handbook. We systematically searched for literature in relevant databases and conducted a grey literature search which was last updated in January 2016.Selection criteria: Randomized controlled trials that included individuals who were already, or at-risk of becoming, homeless were included if they examined the effectiveness of relevant interventions on homelessness or housing stability. There were no limitations regarding language, country or length of homelessness. Two reviewers screened 2,918 abstracts and titles for inclusion. They read potentially relevant references in full, and included relevant studies in the review.Data collection and analysis: We pooled the results and conducted meta-analyses when possible. Our certainty in the primary outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation for effectiveness approach (GRADE).Results: We included 43 relevant studies (described in 78 publications) that examined the effectiveness of housing programs and/or case management services on homelessness and/or housing stability. The results are summarized below. Briefly, we found that the included interventions performed better than the usual services in all comparisons. However, certainty in the findings varied from very low to moderate. Most of the studies were assessed as having high risk of bias due to poor reporting, lack of blinding, or poor randomization and/or allocation concealment of participants.Case management: Case management is a process where clients are assigned case managers who assess, plan and facilitate access to health and social services necessary for the client's recovery. The intensity of these services can vary. One specific model is Critical time intervention, which is based on the same principles, but offered in three three-month periods that decrease in intensity.High intensity case management compared to usual services has generally more positive effects: It probably reduces the number of individuals who are homeless after 12-18 months by almost half (RR=0.59, 95%CI=0.41 to 0.87)(moderate certainty evidence); It may increase the number of people living in stable housing after 12-18 months and reduce the number of days an individual spends homeless (low certainty evidence), however; it may have no effect on the number of individuals who experience some homelessness during a two year period (low certainty evidence). When compared to low intensity case management, it may have little or no effect on time spent in stable housing (low certainty evidence).Critical time intervention compared to usual services may 1) have no effect on the number of people who experience homelessness, 2) lead to fewer days spent homeless, 3) lead to more days spent not homeless and, 4) reduce the amount of time it takes to move from shelter to independent housing (low certainty evidence).Abstinence-contingent housing programs: Abstinence-contingent housing is housing provided with the expectation that residents will remain sober. The results showed that abstinence-contingent housing may lead to fewer days spent homeless, compared with usual services (low certainty evidence).Non-abstinence-contingent housing programs: Non-abstinence-contingent housing is housing provided with no expectations regarding sobriety of residents. Housing First is the name of one specific non-abstinence-contingent housing program. When compared to usual services Housing First probably reduces the number of days spent homeless (MD=-62.5, 95%CI=-86.86 to -38.14) and increases the number of days in stable housing (MD=110.1, 95%CI=93.05 to 127.15) (moderate certainty evidence). In addition, it may increase the number of people placed in permanent housing after 20 months (low certainty evidence).Non-abstinence-contingent housing programs (not specified as Housing First) in combination with high intensity case management may reduce homelessness, compared to usual services (low certainty evidence). Group living arrangements may be better than individual apartments at reducing homelessness (low certainty evidence).Housing vouchers with case management: Housing vouchers is a housing allowance given to certain groups of people who qualify. The results showed that it mayreduce homelessness and improve housing stability, compared with usual services or case management (low certainty evidence).Residential treatment with case management: Residential treatment is a type of housing offered to clients who also need treatment for mental illness or substance abuse. We found that it mayreduce homelessness and improve housing stability, compared with usual services (low certainty evidence).Authors' conclusions: We found that a range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services. The findings showed no indication of housing programs or case management resulting in poorer outcomes for homeless or at-risk individuals than usual services.Aside from a general need for better conducted and reported studies, there are specific gaps in the research. We identified research gaps concerning: 1)Disadvantaged youth; 2) Abstinence-contingent housing with case management or day treatment; 3) Non-abstinence contingent housing, specifically different living arrangements (group vs independent living); 4) Housing First compared to interventions other than usual services, and; 5) All interventions from contexts other than the USA.

What Works? Toward a New Classification System for Mental Health Supported Accommodation Services: The Simple Taxonomy for Supported Accommodation (STAX-SA)

Inconsistent terminology and variation in service models have made synthesis of the supported accommodation literature challenging. To overcome this, we developed a brief, categorical taxonomy that aimed to capture the defining features of different supported accommodation models: the simple taxonomy for supported accommodation (STAX-SA). Data from a previous review of existing classification systems were used to develop the taxonomy structure. After initial testing and amendments, the STAX-SA and an existing taxonomy were applied to 132 supported accommodation service descriptions drawn from two systematic reviews and their performance compared. To assess external validity, the STAX-SA was distributed to a sample of supported accommodation managers in England and they were asked to use it to classify their services. The final version of the STAX-SA comprised of five supported accommodation 'types', based on four domains; Staffing location; Level of support; Emphasis on move-on; and Physical setting. The STAX-SA accurately categorized 71.1% (n = 94) of service descriptions, outperforming the comparison tool, and was not affected by publication date or research design. The STAX-SA effectively discriminated between 'real world' service models in England and 53.2% (n = 17) of service managers indicated that the taxonomy was 'Very effective' or 'Extremely effective' in capturing key characteristics of their service. The STAX-SA is an effective tool for classifying supported accommodation models and represents a promising approach to synthesizing the extant effectiveness literature. The authors recommend the development of reporting guidelines for future supported accommodation publications to facilitate comparison between models.

Independent housing and support for people with severe mental illness: systematic review

OBJECTIVE

To systematically explore the outcomes of Independent Housing and Support (IHS) for people with severe mental disorders when compared to other residential settings.

METHOD

Systematic review of Randomised and Non-Randomised Controlled Trials of publications that analyse the outcomes of living in independent settings versus institutionalised accommodation. Risk of bias assessment was adapted from the Cochrane Collaboration's ACROBAT-Tool. The analysis was conducted separately for publications with homeless and non-homeless people.

RESULTS

Twenty-four publications from studies with homeless people and eight publications from studies with non-homeless people were included. Risk of bias was much lower in studies with the homeless. No RCT was found in the sample of publications with the non-homeless. Overall, results from Independent Housing and Support-settings are not inferior to results from institutionalised settings.

CONCLUSION

The results indicate that Independent Housing and Support-settings provide at least similar outcomes than residential care. We propose that clients' preferences should determine the choice of housing setting.

Canadian Practice Guidelines for Comprehensive Community Treatment for Schizophrenia and Schizophrenia Spectrum Disorders

OBJECTIVE

The objective of this review is to identify the features and components of a comprehensive system of services for people living with schizophrenia. A comprehensive system was conceived as one that served the full range of people with schizophrenia and was designed with consideration of the incidence and prevalence of schizophrenia. The system should provide access to the full range of evidence-based services, should be recovery oriented, and should provide patient-centred care.

METHOD

A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders. The guidelines were rated by at least 2 raters, and recommendations adopted were primarily drawn from the National Institute for Clinical Excellence (2014) Guideline on Psychosis and Schizophrenia in adults and the Scottish Intercollegiate Guidelines Network guidelines on management of schizophrenia.

RESULTS

The recommendations adapted for Canada cover the range of services required to provide comprehensive services.

CONCLUSIONS

Comprehensive services for people with schizophrenia can be organized and delivered to improve the quality of life of people with schizophrenia and their carers. The services need to be organized in a system that provides access to those who need them.

The association between residential eviction and syringe sharing among a prospective cohort of street-involved youth

BACKGROUND

Syringe sharing is a high-risk practice associated with the transmission of infectious diseases, such as HIV and HCV. While youth who contend with housing instability are known to be more likely to engage in high-risk substance use, the potential relationship between being evicted from housing and syringe sharing has not been examined. This study assessed whether residential eviction was associated with syringe sharing among street-involved youth in Vancouver, Canada.

METHODS

Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth who use drugs age 14-26 in Vancouver, Canada. The study period was June 2007 to May 2014, and the potential relationship between residential eviction and syringe sharing was analyzed using multivariable generalized estimating equations (GEE) logistic regression.

RESULTS

Among 405 street-involved youth who injected drugs, 149 (36.8%) reported syringe sharing, defined as borrowing or lending a syringe, at some point during the study period. In a multivariable GEE analysis, recent residential eviction remained independently associated with syringe sharing (adjusted odds ratio (AOR) = 1.72, 95% confidence interval (CI): 1.16-2.57), after adjusting for potential confounders.

CONCLUSIONS

Syringe sharing was significantly elevated among youth who had recently been evicted from housing. These findings indicate that policy and programmatic interventions that increase housing stability may help mitigate high-risk substance use practices among vulnerable youth.

Community residential facilities in mental health services: A ten-year comparison in Lombardy

Residential mental health services grew steadily since 2000 in Italy. A reorganisation of residential facilities was implemented in 2007 in Lombardy, introducing supported housing in addition to staffed facilities. We compare the provision and characteristics of residential facilities in the 2007 and 2016. In 2007 there were 3462 beds (35.9/100,000 population) in 276 facilities. In 2016 beds were 4783 (47.8/100,000) in 520 facilities. The increase were unevenly distributed in the public and private sector, and the overall increase was due to a higher increase in the private sector. 72% of beds were in highly supervised facilities in 2007 and 66% in 2016. The public sector managed more facilities with a rehabilitation goal, while the private sector more for long-term accommodation. Mean numbers of beds were higher in facilities managed by the private sector in both years. The 2007 reorganisation and the stop to opening new facilities in the last years were not enough to correct the imbalance between highly supervised and flexible solutions. A wider and more diverse offer might have triggered off an increased demand, rather than a more rational use. Given the costs of highly staffed facilities, and the risk of reproducing custodial models, close evaluation of the use of residential facilities should inform policies.

Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes

Supportive housing has become the dominant model in the United States to provide housing to the chronically homeless and to improve their housing stability and health. Most supportive housing programs follow a "housing first" paradigm modeled after the Pathways to Housing program in New York City. However, components of housing first supportive housing models were poorly defined, and supportive models have varied considerably in their dissemination and implementation to other parts of the country. Recently, research has been conducted to determine the fidelity by which specific housing programs adhere to the Pathways Housing First model. However, evidence regarding which combination of components leads to better health outcomes for particular subpopulations is lacking. This article presents results from qualitative interviews with supportive housing providers in the Chicago, Illinois, metropolitan area. Supportive housing varied according to housing configuration (scattered-site vs. project-based) and service provision model (low-intensity case management, intensive case management and behavioral health), resulting in 6 basic types. Supportive housing programs also differed in services they provided in addition to case management and the extent to which they followed harm-reduction versus abstinence policies. Results showed advantages and disadvantages of each of the 6 basic types. Comparative effectiveness research may help identify which program components lead to better health outcomes among different subpopulations of homeless. Future longitudinal research will use the identified typology and other factors to compare the housing stability and health outcomes of supportive housing residents in programs that differ along these dimensions. (PsycINFO Database Record

A qualitative study of how people with severe mental illness experience living in sheltered housing with a private fully equipped apartment

BACKGROUND

There are a number of supported housing options for people with severe mental illness (SMI), but limited knowledge about residents' experiences. The aim of this study was to explore how people with SMI experienced sheltered housing consisting of both a private fully equipped apartment and a shared accommodation room for socializing.

METHODS

Fourteen people with SMI living in sheltered housing apartments participated in a qualitative study with semi-structured face to face individual or group interviews.

RESULTS

Residents' access to the service providers in the sheltered housing, who were seen as both "ordinary people" and skilled to observe symptom changes at an early stage, were major factors for the perception of security. In addition, residents highlighted the possibility of living in a fully equipped apartment, and having access to a shared accommodation room to connect with other residents. Having a fully equipped apartment including their own equipment such as a washing machine was said to help reduce conflicts. Short tenancy agreements made some informants feel insecure. It was also essential to have meaningful daily activities outside the residence to avoid re-hospitalization.

CONCLUSIONS

The positive experience was connected to having a fully private equipped apartment including shared accommodation room. The service providers should be aware of the dilemma with in-house support, to make residents feel secure versus increased dependency on service providers.

Research, Data, and Evidence-Based Treatment Use in State Behavioral Health Systems, 2001-2012

OBJECTIVE

Empirical study of public behavioral health systems' use of data and their investment in evidence-based treatments (EBTs) is limited. This study describes trends in state-level EBT investment and research supports from 2001 to 2012.

METHODS

Data were from National Association for State Mental Health Program Directors Research Institute (NRI) surveys, which were completed by representatives of state mental health authorities (SMHAs). Multilevel models examined change over time related to state adoption of EBTs, numbers of clients served, and penetration rates for six behavioral health EBTs for adults and children: supported housing, supported employment, assertive community treatment, therapeutic foster care, multisystemic therapy, and functional family therapy. State supports related to research, evaluation, and information management were also examined.

RESULTS

Increasing percentages of states reported funding an external research center, promoting the adoption of EBTs through provider contracts, and providing financial incentives for EBTs. Decreasing percentages of states reported promoting EBT adoption through stakeholder mobilization, monitoring fidelity, and specific budget requests. There was greater reported use of adult-focused EBTs (65%-80%) compared with youth-focused EBTs (25%-50%). Overall penetration rates of EBTs were low (1%-3%) and EBT adoption by states showed flat or declining trends. SMHAs' investment in data systems and use of research showed little change.

CONCLUSIONS

SMHA investment in EBTs, implementation infrastructure, and use of research has declined. More systematic measurement and examination of these metrics may provide a useful approach for setting priorities, evaluating success of health reform efforts, and making future investments.

Development of a Measure of Housing and Housing Services

The Housing Program Measure (HPM) was designed to document critical elements of a range of housing program types and associated services. Qualitative methods, including literature review and open-ended interviews, were used to determine pertinent HPM domains and to develop the pool of items. The measure was pre-tested, and reliability and validity analyses were applied to revise and strengthen the measure. The resulting measure furthers homelessness research by providing a tool that can be used to define housing and housing services interventions across diverse projects and disciplines, to facilitate program management by matching housing resources to the needs of homeless individuals, and to support model development by measuring progress to goals.

Psychosocial functioning of individuals with schizophrenia in community housing facilities and the psychiatric hospital in Zurich

Individuals with severe mental illness frequently have difficulties in obtaining and maintaining adequate accommodation. If they are not willing or able to adapt to requirements of traditional supported housing institutions they may live in sheltered and emergency accommodation. Adequate mental health services are rarely available in these facilities. The aim of the present study was to evaluate mental health, functional and social status of individuals living in community sheltered housing facilities. A cross-sectional survey of n=338 individuals in sheltered housing compared to a sample of patients at intake in acute inpatient psychiatry (n=619) concerning clinical and social variables was carried out in the catchment area of Zurich. Matched subsamples of individuals with schizophrenia (n=168) were compared concerning functioning and impairments on the Health of the Nation Outcome Scales (HoNOS). Individuals with schizophrenia in sheltered housing (25% of the residents) have significantly more problems concerning substance use, physical illness, psychopathological symptoms other than psychosis and depression, and relationships, daily activities and occupation than patients with schizophrenia at intake on an acute psychiatric ward. Community sheltered accommodation although conceptualized to prevent homelessness in the general population de facto serve as housing facilities for individuals with schizophrenia and other severe mental illness.

Housing First for People With Severe Mental Illness Who Are Homeless: A Review of the Research and Findings From the At Home-Chez soi Demonstration Project

OBJECTIVE

To provide a review of the extant research literature on Housing First (HF) for people with severe mental illness (SMI) who are homeless and to describe the findings of the recently completed At Home (AH)-Chez soi (CS) demonstration project. HF represents a paradigm shift in the delivery of community mental health services, whereby people with SMI who are homeless are supported through assertive community treatment or intensive case management to move into regular housing.

METHOD

The AH-CS demonstration project entailed a randomized controlled trial conducted in 5 Canadian cities between 2009 and 2013. Mixed methods were used to examine the implementation of HF programs and participant outcomes, comparing 1158 people receiving HF to 990 people receiving standard care.

RESULTS

Initial research conducted in the United States shows HF to be a promising approach, yielding superior outcomes in helping people to rapidly exit homelessness and establish stable housing. Findings from the AH-CS demonstration project reveal that HF can be successfully adapted to different contexts and for different populations without losing its fidelity. People receiving HF achieved superior housing outcomes and showed more rapid improvements in community functioning and quality of life than those receiving treatment as usual.

CONCLUSIONS

Knowledge translation efforts have been undertaken to disseminate the positive findings and lessons learned from the AH-CS project and to scale up the HF approach across Canada.

Perceptions of private market landlords who rent to tenants of a Housing First program

The rental of housing units by landlords to participants in Housing First (HF) programs is critical to the success of these programs. Therefore, it is important to understand the experiences of landlords with having these individuals as tenants. The paper presents findings of qualitative interviews with 23 landlords who rented to tenants from a HF program located in a small city and adjoining rural area in eastern Canada and in which approximately 75 % of tenants had been housed for at least six consecutive months at 2 years in the program. Findings showed that landlords are motivated to rent to HF tenants for financial and pro-social reasons. They reported holding a range of positive, neutral, and negative perceptions of these tenants. They identified problems encountered with some HF tenants that included disruptive visitors, conflict with other tenants, constant presence in their apartments, and poor upkeep of units. On the other hand, landlords perceived HF tenants as being mostly good tenants who are similar to their other tenants. Implications for practice in the context of HF programs are discussed.

Resident and proprietor perspectives on a recovery orientation in community-based housing

OBJECTIVE

Stable housing is a fundamental human right, and an important element for both mental health recovery and social inclusion among people with serious mental illness. This article reports findings from a study on the recovery orientation of structured congregate community housing services using the Recovery Self-Assessment Questionnaire (RSA) adapted for housing (O'Connell, Tondora, Croog, Evans, & Davidson, 2005).

METHODS

The RSA questionnaires were administered to 118 residents and housing providers from 112 congregate housing units located in Montreal, Canada.

RESULTS

Residents rated their homes as significantly less recovery-oriented than did proprietors, which is contrary to previous studies of clinical services or Assertive Community Treatment where RSA scores for service users were significantly higher than service provider scores. Findings for both groups suggest the need for improvement on 5 of 6 RSA factors. While proprietors favored recovery training and education, and valued resident opinion and experience, vestiges of a traditional medical model governing this housing emerged in other findings, as in agreement between the 2 groups that residents have little choice in case management, or in the belief among proprietors that residents are unable to manage their symptoms.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study demonstrates that the RSA adapted for housing is a useful tool for creating recovery profiles of housing services. The findings provide practical guidance on how to promote a recovery orientation in structured community housing, as well as a novel approach for reaching a common understanding of what this entails among stakeholders. (PsycINFO Database Record

Experiences of Tenants with Serious Mental Illness Regarding Housing Support and Contextual Issues: A Meta-Synthesis

This study aimed to analyze and synthesize findings from qualitative studies that explored the experiences of tenants with serious mental illness regarding housing support and contextual issues. Twenty-four articles were identified using a systematic search strategy. The total number of informants was N = 769. The reported findings were transcribed and analyzed using a systematic text condensation approach. The tenants' experiences were categorized into two main categories and subcategories (in parenthesis): Support Issues (Experience of Support Needs, Experiences with Receiving Support, Experiences with Support Approach) and Contextual Issues (Neighborhood Experiences, Community Experiences). The subcategories, with themes and subthemes, offer an in-depth understanding of the tenants' complex experiences concerning housing support and contextual issues.

Understanding Housing Delays and Relocations Within the Housing First Model

This study explores factors contributing to delays and relocations during the implementation of the Housing First model in Toronto, Ontario. While interruptions in housing tenure are expected en route to recovery and housing stability, consumer and service provider views on finding and keeping housing remain largely unknown. In-person interviews and focus groups were conducted with 48 study participants, including 23 case managers or housing workers and 25 consumers. The following three factors contributed to housing delays and transfers: (1) the effectiveness of communication and collaboration among consumers and service providers, (2) consumer-driven preferences and ambivalence, and (3) provider prioritization of consumer choice over immediate housing access. Two strategies--targeted communications and consumer engagement in housing searches--supported the housing process. Several factors affect the timing and stability of housing. Communication between and among providers and consumers, and a shared understanding of consumer choice, can further support choice and recovery.

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.

Housing first reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial

BACKGROUND

Homelessness and mental illness have a strong association with public disorder and criminality. Experimental evidence indicates that Housing First (HF) increases housing stability and perceived choice among those experiencing chronic homelessness and mental disorders. HF is also associated with lower residential costs than common alternative approaches. Few studies have examined the effect of HF on criminal behavior.

METHODS

Individuals meeting criteria for homelessness and a current mental disorder were randomized to one of three conditions treatment as usual (reference); scattered site HF; and congregate HF. Administrative data concerning justice system events were linked in order to study prior histories of offending and to test the relationship between housing status and offending following randomization for up to two years.

RESULTS

The majority of the sample (67%) was involved with the justice system, with a mean of 8.07 convictions per person in the ten years prior to recruitment. The most common category of crime was "property offences" (mean=4.09). Following randomization, the scattered site HF condition was associated with significantly lower numbers of sentences than treatment as usual (Adjusted IRR=0.29; 95% CI 0.12-0.72). Congregate HF was associated with a marginally significant reduction in sentences compared to treatment as usual (Adjusted IRR=0.55; 95% CI: 0.26-1.14).

CONCLUSIONS

This study is the first randomized controlled trial to demonstrate benefits of HF among a homeless sample with mental illness in the domain of public safety and crime. Our sample was frequently involved with the justice system, with great personal and societal costs. Further implementation of HF is strongly indicated, particularly in the scattered site format. Research examining interdependencies between housing, health, and the justice system is indicated.

TRIAL REGISTRATION

ISRCTN57595077.

A domains-based taxonomy of supported accommodation for people with severe and persistent mental illness

PURPOSE

A lack of definitional clarity in supported accommodation and the absence of a widely accepted system for classifying supported accommodation models creates barriers to service planning and evaluation.

METHODS

We undertook a systematic review of existing supported accommodation classification systems. Using a structured system for qualitative data analysis, we reviewed the stratification features in these classification systems, identified the key elements of supported accommodation and arranged them into domains and dimensions to create a new taxonomy. The existing classification systems were mapped onto the new taxonomy to verify the domains and dimensions.

RESULTS

Existing classification systems used either a service-level characteristic or programmatic approach. We proposed a taxonomy based around four domains: duration of tenure; patient characteristics; housing characteristics; and service characteristics. All of the domains in the taxonomy were drawn from the existing classification structures; however, none of the existing classification structures covered all of the domains in the taxonomy.

CONCLUSIONS

Existing classification systems are regionally based, limited in scope and lack flexibility. A domains-based taxonomy can allow more accurate description of supported accommodation services, aid in identifying the service elements likely to improve outcomes for specific patient populations, and assist in service planning.

SOCIAL ROLE VALORIZATION IN COMMUNITY MENTAL HEALTH HOUSING: DOES IT CONTRIBUTE TO THE COMMUNITY INTEGRATION AND LIFE SATISFACTION OF PEOPLE WITH PSYCHIATRIC DISABILITIES?

Despite its importance as a theory in the development of programs for populations with disabilities, social role valorization (SRV) has received relatively little attention in community mental health research. We present findings of a study that examined the relationship of housing-related SRV to community integration and global life satisfaction of persons with psychiatric disabilities. The housing environments and associated supports of a group of 73 persons with psychiatric disabilities living in a mid-sized city were assessed using the PASSING rating system on the extent that their housing environments facilitated SRV. In addition, in-person interviews were conducted to determine the levels of physical integration, psychological integration, social integration, and life satisfaction of study participants. Results showed SRV contributing directly to all three types of community integration. Psychological integration was found to mediate the relationship between SRV and life satisfaction. Implications of the findings are discussed. © 2013 Wiley Periodicals, Inc.

Despite obstacles, considerable potential exists for more robust federal policy on community development and health

The implementation of the Affordable Care Act of 2010 and the Obama administration's urban policy create an opportunity to link community development with health in new and powerful ways. The administration's policy emphasizes improved access to and quality of care through coordinated local and regional approaches, expansion of access to healthy food, and the support of environmental health-including clean air, water, and soil-and healthy homes. New federal programs, such as the Affordable Care Act's Community Transformation Grants, seek to prevent death and disability through policy, environmental, programmatic, and infrastructure changes. But fragmented congressional jurisdiction and budget "scoring" rules pose challenges to needed reform. We argue that government agencies need to adopt so-called systems of innovation, or organizational practices and support mechanisms that seek continuously to test new models, refine promising ones, bring to scale those that work best, and restructure or terminate what does not. We also argue that a strong and well-focused policy advocacy coalition is needed to help drive reform focused on the social determinants of health.