The Role of Recovery Housing: Prioritizing Choice in Homeless Services

Women experiencing homelessness and mental illness in a Housing First multi-site trial: Looking beyond housing to social outcomes and well-being

OBJECTIVE

There is scant research on the effectiveness of permanent supportive housing for homeless women with mental illness. This study examines the effectiveness of Housing First with an unprecedentedly large sample of homeless women from five Canadian cities, and explore baseline risk factors that predict social, health and well-being outcomes over a 24 month-period.

METHODS

The At Home/Chez Soi multi-site randomized controlled Housing First trial recruited over 600 women between October 2009 and July 2011. This is a post-hoc subgroup exploratory analysis of self-identified women with at least one follow-up interview who were randomized to Housing First (HF) (n = 374) or treatment-as-usual (TAU) (n = 279) and had at least one follow-up interview. Linear mixed models and generalized estimating equations were used after multiple imputation was applied to address missing data.

RESULTS

At the end of follow-up, the mean percentage of days spent stably housed was higher for women in the intervention 74.8% (95%CI = 71.7%-77.8%) compared with women in the treatment-as-usual group, 37.9% (95%CI = 34.4%-41.3%), p<0.001. With few exceptions, social and mental health outcomes were similar for both groups at 6-, 12-, 18- and 24-months post-enrollment. Suicidality was a consistent predictor of increased mental health symptoms (beta = 2.85, 95% CI 1.59-4.11, p<0.001), decreased quality of life (beta = -3.99, 95% CI -6.49 to -1.49, p<0.001), decreased community functioning (beta = -1.16, 95% CI -2.10 to -0.22, p = 0.015) and more emergency department visits (rate ratio = 1.44, 95% CI 1.10-1.87, p<0.001) over the study period. Lower education was a predictor of lower community functioning (beta = -1.32, 95% CI -2.27 to -0.37, p = 0.006) and higher substance use problems (rate ratio = 1.27, 95% CI 1.06-1.52, p = 0.009) during the study.

CONCLUSIONS

Housing First interventions ensured that women experiencing homelessness are quickly and consistently stably housed. However, they did not differentially impact health and social measures compared to treatment as usual. Ensuring positive health and social outcomes may require greater supports at enrolment for subgroups such as those with low educational attainment, and additional attention to severity of baseline mental health challenges, such as suicidality.

TRIAL REGISTRATION

International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374.

Homelessness and publicly funded substance use disorder treatment in California, 2016-2019: Analysis of treatment needs, level of care placement, and outcomes

INTRODUCTION

Both homelessness and substance use have increased in recent years. People experiencing homelessness (PEH) are at increased risk for health problems and early mortality, both of which can be exacerbated by substance use disorders (SUD). Specialty SUD treatment is likely needed to address substance use among PEH, and more than 232,000 PEH received treatment from U.S. publicly funded SUD programs in 2015. The objective of this paper is to develop a better understanding of the SUD services that PEH receive in publicly funded treatment programs by (1) describing the characteristics and needs of the PEH population served in publicly funded SUD treatment programs, compared to non-PEH populations; (2) determining if differences exist in treatment placement (level of care) for PEH and non-PEH; and (3) gauging how successful programs are in treating PEH compared to non-PEH.

METHODS

Observational study using a two-way fixed effect model to determine associations among homelessness, retention, and outcomes among Medicaid beneficiaries receiving SUD treatment in California from 2016 to 2019 (n = 638,953). The study team used ordinary least squares (OLS) regression to measure the degree to which homelessness was associated with baseline characteristics, SUD services received, and treatment outcomes.

RESULTS

PEH were significantly more likely than non-PEH to be having methamphetamine or heroin as their primary substance. PEH had greater frequency of primary substance use prior to entering treatment, greater ER and hospital utilization, more criminal justice involvement, and greater prevalence of mental health diagnoses and unemployment. PEH were 9.82% more likely than non-PEH to receive residential treatment and 7.11% less likely than non-PEH to receive treatment intensive outpatient modalities. Homelessness was associated with an 11.90% decrease in retention, and a 19.40% decrease in successful discharge status. These trends were consistent across outpatient, intensive outpatient, and residential modalities.

CONCLUSIONS

Developing SUD treatment capacity and housing supports can improve treatment outcomes for PEH. Potential strategies to improve SUD services for PEH include providing more contingency management, opioid pharmacotherapies, programming designed to treat individuals with co-occurring mental health disorders, and resources for housing options that can support PEH in their recovery.

What treatment and services are effective for people who are homeless and use drugs? A systematic 'review of reviews'

BACKGROUND

People who experience homelessness and those vulnerably housed experience disproportionately high rates of drug use and associated harms, yet barriers to services and support are common. We undertook a systematic 'review of reviews' to investigate the effects of interventions for this population on substance use, housing, and related outcomes, as well as on treatment engagement, retention and successful completion.

METHODS AND FINDINGS

We searched ten electronic databases from inception to October 2020 for reviews and syntheses, conducted a grey literature search, and hand searched reference lists of included studies. We selected reviews that synthesised evidence on any type of treatment or intervention that reported substance use outcomes for people who reported being homeless. We appraised the quality of included reviews using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the Scale for the Assessment of Narrative Review Articles. Our search identified 843 citations, and 25 reviews met the inclusion criteria. Regarding substance use outcomes, there was evidence that harm reduction approaches lead to decreases in drug-related risk behaviour and fatal overdoses, and reduce mortality, morbidity, and substance use. Case management interventions were significantly better than treatment as usual in reducing substance use among people who are homeless. The evidence indicates that Housing First does not lead to significant changes in substance use. Evidence regarding housing and other outcomes is mixed.

CONCLUSIONS

People who are homeless and use drugs experience many barriers to accessing healthcare and treatment. Evidence regarding interventions designed specifically for this population is limited, but harm reduction and case management approaches can lead to improvements in substance use outcomes, whilst some housing interventions improve housing outcomes and may provide more stability. More research is needed regarding optimal treatment length as well as qualitative insights from people experiencing or at risk of homelessness.

The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder

BACKGROUND

Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths.

CONCLUSIONS

Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.

Long-term effects of rent supplements and mental health support services on housing and health outcomes of homeless adults with mental illness: extension study of the At Home/Chez Soi randomised controlled trial

BACKGROUND

Housing First is increasingly implemented for homeless adults with mental illness in large urban centres, but little is known about its long-term effectiveness. The At Home/Chez Soi randomised controlled trial done in five cities in Canada showed that Housing First improved housing stability and other select health outcomes. We extended the At Home/Chez Soi trial at the Toronto site to evaluate the long-term effects of the Housing First intervention on housing and health outcomes of homeless adults with mental illness over 6 years.

METHODS

The At Home/Chez Soi Toronto study was a randomised, controlled trial done in Toronto (ON, Canada). Here, we present the results of an extension study done at the same site. Participants were homeless adults (aged ≥18 years) with a serious mental disorder with or without co-occurring substance use disorder. In phase 1, participants were stratified by level of need for mental health support services (high vs moderate), and randomly assigned (1:1) using adaptive randomisation procedures to Housing First with assertive community treatment (HF-ACT), Housing First with intensive case management (HF-ICM), or to treatment as usual (TAU). Participants with moderate support needs were further stratified by ethnoracial status. Considering the nature of the Housing First intervention, study participants and study personnel were not masked to group assignment. Phase 1 participants could choose to enrol in the extension study (phase 2). The primary outcome was the rate of days stably housed per year analysed in the modified intention-to-treat population, which included all randomly assigned participants who had at least one assessment for the primary outcome. Participants contributed data to the study up to the point of their last interview. Multilevel multiple imputation was used to handle missing data. The trial was registered with ISRCTN, ISRCTN42520374.

FINDINGS

Between Oct 1, 2009, and March 31, 2013, 575 individuals participated in phase 1 of the Toronto Site At Home/Chez Soi study (197 [34%] participants with high support needs and 378 [66%] with moderate support needs). Of the 378 participants with moderate support needs, 204 were randomly assigned to receive the HF intervention with ICM or with ethnoracial-specific ICM services (HF-ER-ICM; HF-ICM or HF-ER-ICM groups) and 174 were randomly assigned to TAU. Of the 197 participants with high support needs, 97 were randomly assigned to receive the HF intervention with ACT (HF-ACT treatment group) and 100 were randomly assigned to TAU group. Between Jan 1, 2014, and March 31, 2017, 414 (81%) of 575 phase 1 participants participated in the extended phase 2 study. The median duration of follow-up was 5·4 years (IQR 2·1-5·9). Among phase 2 participants, 141 had high support needs (79 participants in the HF-ACT group; 62 participants in the TAU group), and 273 had moderate support needs (160 participants in the HF-ICM or HF-ER-ICM group; 113 participants in the TAU group). 187 high support needs participants (93 participants in the HF-ACT group, 94 participants in the TAU group), and 361 moderate support needs participants (201 participants in the HF-ICM or HF-ER-ICM group, 160 participants in the TAU group) were included in the modified intention-to-treat analysis for the primary outcome. The number of days spent stably housed was significantly higher among participants in the HF-ACT and HR-ICM or HF-ER-ICM groups than participants in the TAU groups at all timepoints. For participants with moderate support needs, the rate ratio (RR) of days stably housed in the Housing First group, compared with TAU, was 2·40 (95% CI 2·03-2·83) in year 1, which decreased to 1·13 (1·01-1·26) in year 6. The RR of days stably housed for participants with high support needs, compared with TAU, was 3·02 (2·43-3·75) in year 1 and 1·42 (1·19-1·69) in year 6. In year 6, high support needs participants in the Housing First group spent 85·51% of days stably housed compared with 60·33% for the TAU group, and moderate needs participants in the Housing First group spent 88·16% of days stably housed compared with 78·22% for the TAU group.

INTERPRETATION

Rent supplements and mental health support services had an enduring positive effect on housing stability for homeless adults with mental illness in a large, resource-rich urban centre, with a larger impact on individuals with high support needs than moderate support needs.

FUNDING

Mental Health Commission of Canada, Ontario Ministry of Health and Long-Term Care, and the Canadian Institute of Health Research.

The impact of a short-term cohousing initiative among schizophrenia patients, high school students, and their social context: A qualitative case study

Background

A number of programs have been developed to promote the contact between adolescents and mentally-ill patients, in order to break the stigma, improve understanding, promote mental health and prevent substance abuse. The aim of this study was to describe the experience of patients with schizophrenia, high school students, and their social context, participating in a short-term cohousing initiative.

Methods

A qualitative case-study approach was implemented. Patients with schizophrenia from the San Juan de Dios Psychiatric Hospital, female students from Almen High School, and participants from their social context (parents, hospital staff, and teachers) were included, using purposeful sampling. Data were collected from 51 participants (15 patients, nine students, 11 hospital staff, six teachers, 10 parents) via non-participant observation, focus groups, informal interviews, researchers’ field notes and patients’ personal diaries and letters. A thematic analysis was performed.

Results

The themes identified included a) learning to live together: students and patients participate and learn together; b) the perception of the illness and the mentally-ill: the barrier between health and disease is very slim, and society tends to avoid contact with those who are ill; c) change: a transformation takes place in students, in their self-perception, based on the real and intense nature of the experience; d) a trial and an opportunity: patients test their ability to live outside the hospital; e) discharge and readmission: discharge is experienced as both a liberation and a difficulty, whereas relapse and readmission are experienced as failures.

Conclusions

Our findings can help us to better understand schizophrenia and encourage a more positive approach towards both the illness and those who suffer from it. These results may be used for the development of cohousing programs in controlled environments.

The Architecture of Recovery: Two Kinds of Housing Assistance for Chronic Homeless Persons with Substance Use Disorders

PURPOSE

Roughly half a million persons in the United States are homeless on any given night and over a third of those individuals have significant alcohol/other drug (AOD) problems. Many are chronically homeless and in need of assistance for a variety of problems. However, the literature on housing services for this population has paid limited attention to comparative analyses contrasting different approaches.

APPROACH

We examined the literature on housing models for homeless persons with AOD problems and critically analyzed how service settings and operations aligned with service goals.

FINDINGS

We found two predominant housing models that reflect different service goals: Sober Living Houses (SLHs) and Housing First (HF). SLHs are communally based living arrangements that draw on the principles of Alcoholics Anonymous. They emphasize a living environment that promotes abstinence and peer support for recovery. HF is based on the premise that many homeless persons with substance abuse problems will reject abstinence as a goal. Therefore, the HF focus is providing subsidized or free housing and optional professional services for substance abuse, psychiatric disorders and other problems.

PRACTICAL IMPLICATIONS

If homeless service providers are to develop comprehensive systems for homeless persons with AOD problems, they need to consider important contrasts in housing models, including definitions of "recovery," roles of peer support, facility management, roles for professional service, and the architectural designs that support the mission of each type of housing.

ORIGINALITY

This paper is the first to consider distinct consumer choices within homeless service systems and provide recommendations to improve each based upon an integrated analysis that considers how architecture and operations align with service goals.

Housing Status, Psychiatric Symptoms, and Substance Abuse Outcomes Among Sober Living House Residents over 18 Months

Studies show individuals entering sober living recovery houses (SLHs) make significant, sustained improvement on measures of substance abuse problems, employment, and arrests. The current study assessed changes in housing status among SLH residents over 18 months and the relative influences of housing status and psychiatric distress on substance abuse outcomes. Two hundred forty one men and 58 women, all age 18 and older, were interviewed within their first week of entering 20 SLHs and again at 6-, 12-, and 18-month follow-up. Between entry into the SLHs and 18-month follow-up homelessness declined from 16% to 4%, marginal housing declined from 66% to 46%, and stable housing increased from 13% to 27%. Psychiatric severity was generally mild to moderate in severity, but nevertheless showed improvement over the 18-month study period. Multivariate models showed worse substance abuse outcomes for residents with higher psychiatric distress and unstable housing. Relative to persons with stable housing, those who were homeless or marginally housed had worse outcomes and those in SLHs had better outcomes. Overall, we conclude that individuals entering SLHs show improvement in housing status and psychiatric distress, both of which are associated with better substance abuse outcomes.