Pan-Canadian Project on Mental Health and Homelessness

1. Pan-Canadian Project on Mental Health and Homelessness Tim Aubry, Ph.D., C.Psych. National Research Team Member & Co-lead of Moncton Site

2. Homelessness in Canada • There are no accurate estimates of homelessness in Canada; but Canada’s National Secretariat on Homelessness suggests around 150,000 Canadians are homeless; other reports suggest it could be as high as 300,0001 • Serious mental illness, substance abuse and suicidal behaviours are more common among the homeless than the general population • People who are homeless use more government services; British Columbia found costs for health, criminal justice and social services is 33% higher for people who are homeless than for people with housing • Many people experiencing homelessness and mental health issues face marginalization and isolation

3. At Home/Chez Soi • Announced in Federal budget February 2008 • $ 110M over 5 years • Vancouver, Winnipeg, Toronto, Montreal, Moncton • Early development • Building on what exists • Community collaboration • RFA process that included research and services

4. Principles • People with lived experience are central • Build on existing work • Support knowledge exchange • Foster collaboration and partnerships • Work with communities to ensure lasting results and buy-in • Address fragmentation through improved system integration • Plan for sustainability

5. Why Research? Unanswered questions about what works, with whom, how and at what cost Evidence to inform policy and practice Leveraging of time-limited resources to maximize potential impact

6. Research on Interventions forHomeless People with SMI Meta-analysis of 16 effectiveness (Nelson, Aubry, & Lafrance, 2007) Housing with support, ACT, & ICM reduce homelessness, and hospitalizations as well as produce other positive outcomes Best approach in the literature to help people achieve stable housing is “Pathways - Housing First” combining regular housing, rent subsidies, and intensive support delivered by an ACT team (Tsemberis & Eisenberg, 2000; Tsemberis, Gulcur, & Nakae, 2004)

7. “Housing First” • Recovery oriented -- client choice at the centre • Clients pay < 30% of their income for housing. • Housing in self-contained units, mostly private sector and scattered site • Treatment and support services are voluntary, individualized, culturally appropriate, portable • No conditions on housing readiness. Tenancy not tied to engagement in treatment. • Requirements: rent paid directly to the landlord, once a week visits by support team or case manager for pre-determined period. • Evaluated and found to be a cost-effective approach for retaining clients in housing in New York City

8. Design and Questions • Pragmatic, multi-site, randomized, mixed methods field trial • Effectiveness and cost-effectiveness of Housing First (+ supports) model in Canadian contexts • Model being tested at two levels of intensity (high needs = ACT) moderate (ICM) vs. usual care • Being extended to include primary care, vocational supports, and special populations

9. Why a Multi-Site Trial? Opportunity to scale up quickly established best practice approaches. i.e. “bring interventions that are proven and effective to the public.” Pooling of data increases numbers and possibilities for analysis Cross-site comparisons provide information about implementation in different contexts and increases the policy impact. Economy of scale for technical assistance, knowledge exchange and network building

10. Target Population • Adults (age 18 (19 in Vancouver)) • Homeless (absolutely or precariously housed) • Presence of a serious mental health issue • Targeted # of project participants of over 2000 • Over 1300 are targeted to receive housing and other supports

11. At Home/Chez Soi:Vancouver • Outcomes of individuals with serious addictions e.g. injection • drug use • Intervention third arm includes comparison to a congregate • setting • Unique aspect is impact on media messages

12. At Home/Chez Soi:Winnipeg • Focus is on aboriginal homeless population • Participatory action research • Intervention incl. traditional healing e.g. medicine • wheel, spiritual approaches • Measures include trauma, residential school history

13. At Home/Chez Soi:Toronto • Focus is on needs of diverse ethnocultural groups • Intervention includes modifications for different ethnic groups • Also focus on chronic physical illnesses and access to primary care • Consumers have been very involved

14. At Home/Chez Soi:Montreal • Testing of HF approach in a mental health system in • transition • Intervention includes ISP vocational approaches • Team has contributed to fully bilingual data collection • system

15. At Home/Chez Soi:Moncton • Intervention will blend high and moderate • need services in one - “flexible supports” • Focus is on models for smaller cities • Also testing Housing First approach in rural • areas

16. Why Mixed Methods ? Quantitative = numbers Qualitative = stories • Both necessary to understand implementation of complex programs like Housing First

17. Example ResearchQuestions Quantitative: • What is the effectiveness (incl. cost-effectiveness) of a proven Housing First approach to care in comparison to care as usual for unaccompanied homeless adults with high need living in urban settings*? • What is the effectiveness (incl. cost-effectiveness) of a promising Housing First approach in comparison to care as usual for unaccompanied homeless adults with moderate need living in urban settings? Qualitative: • How do the personal stories and lived experience of participants in the intervention and control conditions differ over time and how can those stories inform the practice, service delivery and policy implications of the study; with particular attention to gender, aboriginal and cultural differences? Mixed Quantitative and Qualitative: • What are the critical ingredients of the Housing First model and modifications needed to effectively implement in it different size cities and to effectively serve particular sub-populations?

18. The Measurement Framework

19. The Administration Protocol

20. Qualitative Research Provide in-depth information about the interventions, the usual care conditions and the participants • 1. UNCOVERING & DESCRIBING: • How this research demonstration project came into being • How the five communities mobilized to develop their proposals and plan their programs • How the five communities implemented their programs • 2. UNDERSTANDING & CONTEXTUALIZING: • The lived experiences of consumers • Specific experiences related to their housing and clinical services • Outcomes of the intervention on consumers • Resulting changes in the lived experiences of consumers

21. Collecting the Data • Data being collected in a highly secured national info • system procured through a competitive process • HD manages the whole process from screening through • last follow-up including randomization • RAs will use outreach approaches and collect data from • participants using laptops and internet keys in the field

22. Milestones To Date • RFA –Nov. 2008/Awards Feb. 2009 • Site Development work began April 1, 2009 • 5 local research/service teams in 5 cities • Each city contributes to core research questions but has also has own questions • First participants 2nd week of October, 2009. Currently at about 50% of target enrollment

23. Acknowledgements “The At Home/Chez Soi Project Team includes: Jayne Barker, Ph.D., Director of Research and Policy, Mental Health Commission of Canada, and Project Lead for the study at the national level; Paula Goering, RN Ph.D., Centre for Addiction and Mental Health and University of Toronto, Research Lead at the national level; and approximately 40 investigators from across Canada and the U.S. In addition there are 5 site coordinators (one for each city where the study is carried out) and numerous lead service and housing providers as well as persons with lived experience.”

24. National Research Team Paula Goering, CAMH, University of Toronto - Lead Carol Adair, University of Calgary Tim Aubry, University of Ottawa Jeffrey Hoch, St. Michael’s Hospital, University of Toronto, University of Western Ontario Geoff Nelson, Wilfrid Laurier University Myra Piat, Douglas Mental Health University Institute; McGill University David Streiner, Baycrest Hospital; University of Toronto Sam Tsemberis, Pathways to Housing, Inc

25. Local PI’s • Moncton: Tim Aubry, University of Ottawa & Jimmy Bourke, Université de Moncton • Toronto: Stephen Hwang, St. Michael’s Hospital, University of Toronto; Vicki Stergiopoulos, St. Michael’s Hospital, University of Toronto, Pat O’Campo, St. Michael’s Hospital, University of Toronto • Montreal: Eric Latimer, Institut Douglas, Université McGill • Winnipeg: Jino Distastio, University of Winnipeg & Jitender Sareen, University of Manitoba • Vancouver: Julian Somers, Simon Fraser University; Michael Krausz University of British Columbia & Jim Frankish, University of British Columbia