Housing First – Mental Health

At Home Chez SoiHousing First was always in a way designed with people experiencing mental health challenges in mind. This is because the model was originally focused on ending chronic homelessness, and both chronic homelessness and homelessness in general occur most often in the context of mental health challenges. Although statistics vary from study to study, on average 2/3 of people experiencing homelessness also have an active mental health challenge. This rate goes as high as 100% in studies of those considered chronically homeless. There is a bit of a chicken/egg debate to be had about mental illness causing homelessness or homelessness causing mental illness, but regardless, the two are intertwined, and it’s likely a case of both/and. As Housing First was designed by those within the sector, it is grounded in research and practice with those with mental health challenges.

So, it comes as no surprise that both historical and recent research is demonstrating that Housing First works with this sub-population. This is also the sub-population for whom we have the most established best practices to draw upon, which is why I wanted to cover it first in this series.

The At Home/Chez Soi project represents one of the largest and most comprehensive reviews of Housing First programs, and it was focused on 2000 homeless Canadians experiencing mental health challenges. Half of the participants continued to receive the usual mental health and housing services available in their community, while the other half received a variety of targeted Housing First interventions through either Assertive Community Treatment (ACT) or Intensive Case Management (ICM).

The Results

It’s hard to argue with the effectiveness of the program based on the results. “Those who received Housing First were, after two years, stably housed 80 per cent of the time, compared to 54 per cent of those who had treatment as usual.” (1)

screenshot-by-nimbus (16)

Additionally, participants showed a rapid decline in shelter use that persisted over time. This coincided with less hospital use, drop-in centre use, and fewer arrests for drug-related offences. (2)  This equated to significant cost savings for the system as a whole, in particular for the 10% of those with highest service needs: “Over the two-year period following study entry, every $10 invested in Housing First services resulted in an average savings of $21.72.” Most importantly, from a perspective of the individual, those in the intervention experienced both better community functioning and improved quality of life, and were overwhelmingly more positive about their life course.

Best Practices for Housing First for Those with Mental Health Challenges

So here is what we can learn about Housing First for this sub-population of people experiencing homelessness:

  1. Housing First is effective across various demographics such as urban/rural, various ethnocultural communities, medium or large cities, and communities with differing existing services.
  2. Services are an essential component of Housing First, particularly for those experiencing a mental health challenge. These services need to be mobile, community-based, not institutional.
  3. Housing provides the foundation for other changes in peoples’ lives, but we can’t be too demanding that those changes happen too quickly if our programs truly have no requirement for being ‘treatment-ready’.
  4. Although there is some room to flex in terms of congregate living or live-in support is communities demand, this is highly discouraged as the best outcomes were seen with those programs that stayed truest to Housing First principles.
  5. The health care system needs to be at the table, if not the lead, in providing Housing First with this population. Because the supports are essential and include either ACT or ICM, health providers are going to be involved.
  6. Services are best de-linked from housing, in that they follow the individual to wherever they choose to reside, not being attached to just one apartment or building.
  7. Self-determination is essential as it goes hand-in-hand with the recovery-oriented approach of mental health care.

I’ll end with a final graph, that tells strongly of the importance of reconfiguring how our system responds to those with housing needs:

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Some Gains on Poverty Reduction

In this blog post from last year on the 2012 annual report on Ontario’s Poverty Reduction Strategy, I sounded the alarm that we were falling behind.  Early gains were not being followed through in terms of increases to child benefits, social assistance, minimum wage, and losses occurred with the transition from CSUMB to CHPI.  In this year’s report, we can see some of the impact of the setbacks, as evidenced by this graph:

Poverty Reduction

You will note that on housing and depth of poverty, our best year was 2010-11, with some ground lost last year.  However, overall the Poverty Reduction Strategy has had some positive impacts.  The greatest impacts came from:

  • All day kindergarten, and enhanced child care
  • Increases to child benefit payments
  • Increases to the minimum wage, when they happened
  • Increases to social assistance rates, when they happened
  • And smaller programs like: employment, mental health, dental, education grants, etc.

All together, this has decreased the child poverty rate in Ontario from 15.2% to 13.6%.  A modest increase, but an increase none-the-less.  However, still a ways away from the 25% decrease that was targeted.

In moving forward, the equation continues to be a simple one.  We can move children out of poverty by providing their families a good income, and affordable housing.  Three key recommendations for achieving this would be:

  • Continued increases to inadequate social assistance rates
  • Significant development of new affordable housing units to work on the 2100 family wait list in London
  • Continued increases to child tax benefits.

Poverty and Food Security

The latest report on household food insecurity in Canada offers some key insight into what exactly food insecurity looks like in our communities.  I was pleased to discover that this national report paralleled exactly the findings of the work I did with the United Way on poverty and policies, which included a look at food security.  There are two key points to highlight:

1) Food insecurity is primarily about poverty, not having enough money.

2) Food insecurity in Canada more often looks like not having quality food versus not having enough food.

What we found in talking to people experiencing poverty about food was that there is actually quite a bit of food available in the community provided someone has the mobility and community knowledge to access it.  There are enough food cupboards, soup kitchens, church meals, and food banks to keep one from starvation.  However, living on this circuit of accessing free food means very poor quality.

Have a look at this table from the report:

Food Security SurveyYou will note that the primary issue is affording food, the second is the quality of food one can afford, and the third is quantity of food.  To me, this highlights that the only way to truly address food security is to address poverty, everything else is a band-aid solution.


A Success Story

Change can be a difficult process.  London is currently in a transition with our homelessness programs to move more resources from managing people while they are homeless, to prevention or rapid re-housing with supports.  This is difficult as it means the typical modes are altered, impacting funding, employment, and processes within the sector.  For example, part of the vision is to reduce the utilization of emergency shelters by providing people more permanent housing alternatives.  This has direct implications for the wonderful organizations who have been providing emergency shelter for years.

This recent report out of Lethbridge Alberta demonstrates that this move from management to prevention and re-housing can work.  This is positive news in a field where we are often just looking to slow worsening trends.  Reductions in support from federal and provincial levels mean that municipal plans can only achieve so much.  However, have a look at Lethbridge’s numbers below:

Lethbridge HomelessnessBy moving people into housing, they have greatly decreased emergency shelter use.  This, along with increased outreach support, has decreased rough sleeping to almost nil.  Extrapolating the curve suggests that by the end of their next 5 year plan, homelessness in Lethbridge will be minimal, hopefully only representing a transition phase as people move into housing.

Now, it’s not all positive.  623 individuals and families continue to wait on the Lethbridge list for affordable housing.  However, even this large wait list is not translating directly into people stuck in shelter (see chart on page 41).  What we in London can learn though is doing this hard work to reorient the system has been shown to have positive results.


The Nuance in the Numbers

Winnipeg & Farm 2009 077Who gets stuck in shelter?  How many are chronically homeless?  Are all the same people using all the same shelter beds?  Is shelter becoming housing?  These are just some of the questions that come up in discussions of refinishing our homelessness and shelter services.  The current goal in London is to move emergency shelters back to being just emergency shelters, not a replacement for affordable housing.  However, to manage this, we need to know something about those who are using these shelters.

This article by Aubry, Farrell, Hwang and Calhoun starts to unpack those numbers, particularly in finding three clusters of shelter use: 1) Temporary (few, short stays); 2) Episodic (many, short stays); 3) Long-stay (few, long stays).  At first blush, the numbers demonstrate what we have long known, that homelessness for most is a temporary situation – with those in the temporary shelter stay cluster accounting for 88-94%.  However, this is a representation of total shelter users over time.  A snapshot of a shelter at a moment in time shows that between 25-40% of current residents are in the Long-stay cluster.

So, although the temporary group represents that most individuals who will have any shelter use, the episodic and long-stay groups will occupy far more of the beds on any given night.  This leads us to consider how best to free up shelter beds?

I would predict that those in the long-stay group are the same individuals identified as needing more support in our work on medical respite: those with the most complex health and social challenges, namely concurrent addictions and mental health challenges.  These individuals require the most supports to be successfully housed, and therefore are more likely to be ‘stuck’ in shelters.  Putting the pressure solely on shelters to move these people out negates that wrap-around supports that are required.

Housing as Health Intervention

DSC02792As a nurse, health professional, and health educator, I spend a lot of time talking about housing.  Working with people experiencing homelessness, there is no shortage of traditional health concerns to be worried about: mental illness, addictions, wounds, communicable diseases, infection, etc.  However, looking at both the cause of and solutions to health issues on the context of homelessness, I come back time and time again to housing.  It can be intimidating trying to gain mastery over another area when healthcare is consuming enough, but making the links across sectors is crucial in creating solutions.

Much of the preliminary work on health and housing was on linking housing as a determinant of health and therefore demonstrating a relationship between these.  This has led to a plethora of studies stating, for example, that homelessness is bad for one’s health.  Newer working (refreshingly, for those who are tired of reading of the same correlations) is digging into intervention studies, and in particular housing as a health intervention.  The report “Housing and Health: Examining the Links” from the Wellesley Institute does exactly this, breaking down the various housing interventions that offer some promise in terms of improved health.

Most interesting to me in the report is the ongoing refinement of the differentiation between a Continuum Model of housing versus a Housing First Model.  In a Continuum Model, the individual is expected to advance along a progression of demonstrated capacity to demonstrate ability to move towards independent, market-rent housing.  In Housing First, housing is provided up-front, and supports to the appropriate degree are attached to the housing.  I personally see the most promise in the Housing First model, as this recognizes that for many, advancement along a continuum is not in the perceivable future.  This is not to give up on people, but to recognize for many, recovery simply looks like survival.

The Role Staff Play in Housing

DSC02789In reviewing the Homes for the Hard to House report by St Leonard’s Society of Canada, what struck me was the role that staff play in terms of housing those who have experienced homelessness.  The transition in homelessness services through 2000-2010 was on using the language of housing first.  Now the common message is housing first with supports.  What supports equates to is people, whether on-site of off-site, those who can provide real assistance when individuals experience challenges that put their housing tenure at risk.  This report offers some practical tips for those creating housing with supports for individuals who have had difficulty with their housing.

The primary recommendation in the report with regards to staff is to ensure that they are well trained.  This of course means individuals with an educational background in human services, such as social work or social service worker training, as well as supplemental certification, and of course work experience.  There are so many individuals that I have had the privilege of working with in social services in London who would fit all of these requirements.  However, organizations face two very real challenges: 1) staff cost, and 2) finding the right people.

Cost is of course a challenge as social services face limited access to funds at all sources of government.  In the context of housing, it may be possible to find funds for capital, but then operations costs of the ‘with supports’ component may be harder to fund. Of course, agencies would be happy to fill their staff compliment with those with a Master’s of Social Work (MSW) degree and 15 years experience, but this comes at a price.  There is often a temptation/pressure to decrease your expectations to meet the realities of your budget.

The other challenge is finding the right people; having an MSW degree does not mean you are good at each and every social service position.  And, there are many great individuals coming out of various social service programs who would be great in an organization but don’t have the years of work experience on their resume.  This is where the suggestion from the report on integrating student placements comes into play to solve both of the concerns I have brought up here.  Students can provide service with no cost as part of placement hours.  Also, having students in can be a great way to get to know people who might be good for you organization.

However, the primary warning is that students require adequate and appropriate supervision.  They are not able to fill in a gap in terms of staffing, but rather can compliment existing staff.  So, rather than thinking of student placements as a core solution to staffing, they should be considered a nice supplement, allowing you to provide the full range of services you might otherwise not be able to fund.  In this way, no proposal for housing with supports should be dependent on placements to be viable.

Mixed Up About Markets

London’s Anti-Poverty Strategy: Literature Review is one of the documents that led to the creation in London of the Child and Youth Network.  The purpose of the Child and Youth Network is to eliminate poverty through strategies focused on children.  In the Literature Review both causes of and solutions to poverty are presented.  In terms of causes, they look at economic trends and identify “Deregulation of business…and elimination of trade barriers” as causing increased poverty.  There is a sense that free markets, although generating wealth, do not distribute it well and actually contribute to growing income inequality.  Ironically, in local solutions to poverty, they identify freeing up markets, including:

“Creation of an economy based on a market in which the price of goods and services are determined through the mutual consent of buyers and sellers.  The role of government is reduced to addressing market failures.”

Do you see the irony?  We know that freeing up markets in increasing poverty and inequality, yet there is a desire locally to attract big businesses for local job creation.  This is the rub, where local urgency blinds us to national and international trends.

All that said, market solutions will never be enough to end poverty, as employment in its current iteration will never be a reality for all.  To end poverty, we must look at specific issues for specific populations, not the least of which would be people experiencing homelessness.  And, within this demographic, there is another group that we need to look at if we want to end homelessness, which is people experiencing a substance addiction.  Until we get smart about working with addictions, we will always have homelessness, and as long as we have homelessness, we will have poverty.


Mental Health Care: Filling in the Gaps

Building all the social housing in the world won’t be enough to end homelessness if we don’t also provide supports in the community for those who need them.  In the context of homelessness, this has much to do with people experiencing an addiction and/or a mental illness.  Knowing that there are serious gaps and deficiencies in mental health services, in Ontario we have been reorienting services is a concerted way since 1998.

The latest step in the reorientation of mental health services in London is a report from the South West LHIN entitled “The Time is Now: A Plan for Enhancing Community-based Mental Health and Addiction Services in the South West LHIN“.  This plan follows other work that focused on acute care services, and focuses on supporting people living in the community.  What is striking about this report is rather than focusing solely on the better organization of care, many clear recommendations are made for increasing services, to fill in the gaps.  This means we need to make serious investments in mental health care in London, including:

  1. 1.0 FTE for community withdrawal services.
  2. 1 new ACT team, at 8.0 FTEs.
  3. 4 new FTEs for case managers.
  4. A mobile crisis support team at 8 FTEs.
  5. 20 new units of supportive housing per year over 5 years.
  6. 2 new FTEs of mental health counsellors.
It’s a lot of coin, but doesn’t begin to compare with the current costs of not adequately treating addictions and mental illness in the community.