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O’Toole TP, Pape LM, Kane V, Diaz M, Dunn A, Rudolph JL, Elnahal S. Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative. JAMA Netw Open 2024; 7:e2353778. [PMID: 38285443 PMCID: PMC10825721 DOI: 10.1001/jamanetworkopen.2023.53778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024] Open
Abstract
Importance Homelessness is a persistent and growing problem. What role health systems should play and how that role is incorporated into larger strategic efforts are not well-defined. Objective To compare homelessness among veterans with that in the general population during a 16-year study period before and after implementation of the Ending Veteran Homelessness Initiative, a program to rehouse veterans experiencing homelessness. Design, Setting, and Participants This national retrospective cohort study using a mixed-methods approach examined annualized administrative (January 1, 2007, to December 31, 2022) and population data prior to (2007-2009) and during (2010-2022) the Ending Veteran Homelessness initiative. Participants included unhoused adults in the US between 2007 and 2022. Exposure Enrollment in Veterans Health Administration (VHA) Homeless Program Office components providing housing, case management, and wrap-around clinical and supportive services. Main Outcomes and Measures Point-in-time (PIT) count data for unhoused veterans and nonveterans during the study period, number of Section 8 housing vouchers provided by Housing and Urban Development-Veterans Administration Supportive Housing, number of community grants awarded by Supportive Services for Veterans and Families, and total number of veterans housed each year. Semistructured interviews with VHA leadership were performed to gain insight into the strategy. Results In 2022, 33 129 veterans were identified in the PIT count. They were predominantly male (88.7%), and 40.9% were unsheltered. During the active years of the Ending Veteran Homelessness initiative, veteran homelessness decreased 55.3% compared with 8.6% for the general population. The proportion of veterans in this cohort also declined from 11.6% to 5.3%. This change occurred during a shift to "housing first" as agency policy to create low-barrier housing availability. It was also coupled with substantial growth in housing vouchers, grants to community partner agencies, and growth in VHA clinical and social programming to provide homeless-tailored wrap-around services and support once participants were housed. Key respondent interviews consistently cited the shift to housing first, the engagement with community partners, and use of real-time data as critical. Conclusions and Relevance In this cohort study of the federal Ending Veteran Homelessness initiative, after program implementation, there was a substantially greater decrease in homelessness among veterans than in the general population. These findings suggest an important role for health systems in addressing complex social determinants of health. While some conditions unique to the VHA facilitated the change in homelessness, lessons learned here are applicable to other health systems.
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Affiliation(s)
- Thomas P. O’Toole
- US Veterans Health Administration, Washington, DC
- Providence Veterans Affairs Health System Center for Innovation in Long Term Services and Support, Providence, Rhode Island
- Division of Medicine and Biology, Alpert Medical School at Brown University, Providence, Rhode Island
| | - Lisa M. Pape
- US Veterans Health Administration, Washington, DC
| | - Vincent Kane
- US Veterans Health Administration, Washington, DC
| | - Monica Diaz
- US Veterans Health Administration, Washington, DC
| | - Anne Dunn
- US Veterans Health Administration, Washington, DC
| | - James L. Rudolph
- Providence Veterans Affairs Health System Center for Innovation in Long Term Services and Support, Providence, Rhode Island
- Division of Medicine and Biology, Alpert Medical School at Brown University, Providence, Rhode Island
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Samosh J, Agha A, Pettey D, Sylvestre J, Aubry T. Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers. Prof Case Manag 2023:01269241-990000000-00008. [PMID: 38037223 DOI: 10.1097/ncm.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF STUDY This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction. PRIMARY PRACTICE SETTING The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction. METHODOLOGY AND SAMPLE Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis. RESULTS Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.
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Affiliation(s)
- Jonathan Samosh
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Ayda Agha
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Donna Pettey
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - John Sylvestre
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Tim Aubry
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
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Slesnick N, Brakenhoff B, Bunger A, Chavez L, Cuthbertson C, Famelia R, Feng X, Fitzpatrick M, Ford J, Hatsu I, Holowacz E, Jaderlund S, Kelleher K, Luthy E, Mallory A, Martin J, Pizzulo A, Stone-Sabali S, Yilmazer T, Wu Q, Zhang J. Lessons learned from housing first, rapid rehousing trials with youth experiencing homelessness. Addict Sci Clin Pract 2023; 18:58. [PMID: 37775777 PMCID: PMC10542262 DOI: 10.1186/s13722-023-00413-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Youth, 18 to 24 years, experiencing homelessness (YEH) are recognized as having developmental challenges dissimilar to older adults. Yet, research on efforts to end homelessness and prevent or intervene in drug use and mental health problems among youth have lagged behind that of adults. The Housing First (HF) Model which underlies Permanent Supportive Housing (PSH) and Rapid Re-Housing (RRH) has become preferred over treatment-first models. METHODS AND RESULTS We provide an overview of PSH and RRH studies to date and summarize our current understanding of their utility for use with YEH. Finally, we review our team's current and past randomized trials testing RRH with YEH, providing lessons learned and recommendations. CONCLUSION Current research efforts to guide best practices are hampered by a lack of fidelity to HF principles, lack of randomized design, and lack of focus on youth. Lessons learned and recommendations from our work are offered to facilitate the future work of those who seek to end homelessness and address drug use and mental health problems among youth.
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Affiliation(s)
- Natasha Slesnick
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA.
| | - Brittany Brakenhoff
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Alicia Bunger
- College of Social Work, The Ohio State University, 1947 N. College Road, Columbus, OH, 43210, USA
| | - Laura Chavez
- Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Caleb Cuthbertson
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Ruri Famelia
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Xin Feng
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Maggie Fitzpatrick
- College of Nursing, The Ohio State University, 1585 Neil Avenue, Columbus, OH, 43210, USA
| | - Jodi Ford
- College of Nursing, The Ohio State University, 1585 Neil Avenue, Columbus, OH, 43210, USA
| | - Irene Hatsu
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Eugene Holowacz
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Soren Jaderlund
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Kelly Kelleher
- Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Ellison Luthy
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Allen Mallory
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Jared Martin
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Alexis Pizzulo
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Steven Stone-Sabali
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Tansel Yilmazer
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Qiong Wu
- Department of Family and Child Sciences, Florida State University, Tallahassee, FL, USA
| | - Jing Zhang
- Department of Human Development and Family Studies, Kent State University, Kent, OH, USA
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Miler JA, Foster R, Hnizdilova K, Murdoch H, Parkes T. ‘It maybe doesn’t seem much, but to me it’s my kingdom’: staff and client experiences of Housing First in Scotland. Drugs: Education, Prevention and Policy 2022. [DOI: 10.1080/09687637.2021.1926429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Joanna Astrid Miler
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Rebecca Foster
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Kristina Hnizdilova
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Helen Murdoch
- Homelessness Services, The Salvation Army, Glasgow, UK
| | - Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
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Fletcher EH, Gabrielian S, Flynn AWP, Greenberg JM, Hovsepian S, Oberman RS, Young AS. Stakeholder perspectives on sustainment of Housing First in a VA permanent supportive housing program. Health Serv Res 2022; 57:374-384. [PMID: 35238030 PMCID: PMC8928030 DOI: 10.1111/1475-6773.13904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the sustainment of Housing First (HF) implementation in a permanent supportive housing program for homeless-experienced veterans, 5 years after practice implementation. STUDY SETTING From 2016 to 2017, primary data were collected from providers and veterans in the Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program at Los Angeles. STUDY DESIGN Guided by the integrated sustainability framework, we performed a mixed-methods study to evaluate the sustainment of HF, an evidence-based practice implemented to improve housing outcomes. To assess sustainment, we measured fidelity to HF in six of seven HUD-VASH teams. These data were integrated with qualitative interviews with providers and veterans who described perceived sustainment to HF and contextual factors that supported or impeded sustainment. DATA COLLECTION Fidelity to HF at 5 years after practice implementation, as a proxy for sustainment, was quantified via surveys with HUD-VASH teams. HUD-VASH providers (n = 51) and 31 veterans participated in semi-structured interviews. Team-based template analyses were used to develop an emergent understanding of stakeholder perspectives on HF sustainment. PRINCIPAL FINDINGS Overall, HUD-VASH teams reported HF sustainment. The lowest fidelity scores were found in the domains of client-to-staff ratios, frequency of client-provider contact, and time to housing. Qualitative findings indicated that outer contextual factors (e.g., housing scarcity) and organizational factors (e.g., staff turnover) impacted HF sustainment. Providers identified changes in leadership and unmet resource needs as impediments to practice sustainment. All stakeholders identified positively with the HF practice and believed that the approach benefited veterans. CONCLUSIONS This snapshot of HF sustainment demonstrates that this practice can be sustained over time. However, strong leadership, organizational resources, and community partnerships are needed. Adaptations to HF in response to outer contextual factors and organizational capacity may result in practice sustainment while allowing for flexibility in service provision.
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Affiliation(s)
- Erica Hua Fletcher
- UCLA/VA Center of Excellence for Veteran Resilience and Recovery, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, California, USA.,Health Services Implementation Unit, VA Greater Los Angeles, Mental Illness Research, Education, and Clinical Center, Los Angeles, California, USA
| | - Sonya Gabrielian
- UCLA/VA Center of Excellence for Veteran Resilience and Recovery, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, California, USA.,Health Services Implementation Unit, VA Greater Los Angeles, Mental Illness Research, Education, and Clinical Center, Los Angeles, California, USA.,HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles, Los Angeles, California, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Anthony W P Flynn
- Health Services Implementation Unit, VA Greater Los Angeles, Mental Illness Research, Education, and Clinical Center, Los Angeles, California, USA.,Department of Counseling Psychology, University of Wisconsin Madison School of Education, Madison, Wisconsin, USA
| | - Jared M Greenberg
- UCLA/VA Center of Excellence for Veteran Resilience and Recovery, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, California, USA.,Health Services Implementation Unit, VA Greater Los Angeles, Mental Illness Research, Education, and Clinical Center, Los Angeles, California, USA.,HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles, Los Angeles, California, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Sona Hovsepian
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Rebecca S Oberman
- Health Services Implementation Unit, VA Greater Los Angeles, Mental Illness Research, Education, and Clinical Center, Los Angeles, California, USA.,HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles, Los Angeles, California, USA
| | - Alexander S Young
- Health Services Implementation Unit, VA Greater Los Angeles, Mental Illness Research, Education, and Clinical Center, Los Angeles, California, USA.,HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles, Los Angeles, California, USA.,Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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6
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Dunt DR, Day SE, Collister L, Fogerty B, Frankish R, Castle DJ, Hoppner C, Stafrace S, Sherwood S, Newton JR, Redston S. Evaluation of a Housing First programme for people from the public mental health sector with severe and persistent mental illnesses and precarious housing: Housing, health and service use outcomes. Aust N Z J Psychiatry 2022; 56:281-291. [PMID: 33966500 DOI: 10.1177/00048674211011702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS AND CONTEXT This paper reports the evaluation of the Doorway program (2015-18) in Melbourne, Australia. Doorway extends the original Housing First (HF) model in providing housing support to people with precarious housing at-risk of homelessness with Serious and Persistent Mental Illnesses (SPMIs) receiving care within Victoria's public mental health system. Doorway participants source and choose properties through the open rental market, and receive rental subsidies, assistance, advocacy and brokerage support through their Housing and Recovery Worker (HRW). The aim of this study is to estimate Doorway's impact on participants' housing, quality of life and mental health service use. METHODOLOGY The study employed a a quasi-experimental study design with a comparison group, adjusted for ten potential confounders. The primary outcome measure was days of secure housing per participant. Secure housing status, health service usage and quality of life (HoNOS) data were extracted from participants' electronic hospital and Doorway records in deidentified, non-reidentifiable form. Analysis for continuous outcome variables was based on multivariate GLM modelling. RESULTS Doorway housed 89 (57%) of 157 accepted participants. The 157 Doorway participants overall were also housed for significantly more days (119.4 extra days per participant) than control participants, albeit after some delay in locating and moving into housing (mean 14 weeks). There was a significant, positive Doorway effect on health outcomes (all and one dimension of the HoNOS). Doorway participants had significantly reduced length of stay during acute and community hospital admissions (7.4 fewer days per participant) compared with the control group. CONCLUSION The Doorway model represents a new and substantial opportunity to house, enhance health outcomes and reduce mental health service use for people with SPMIs from the public mental health sector and at-risk of homelessness.
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Affiliation(s)
| | | | | | | | | | - David J Castle
- Department of Psychiatry, St Vincent's Health, The University of Melbourne, Fitzroy, VIC, Australia; Centre for Complex Interventions, Centre for Addictions and Mental Health, Toronto, ON Canada
| | - Cayte Hoppner
- Adult Mental Health Service, Latrobe Regional Hospital, Traralgon, VIC, Australia
| | - Simon Stafrace
- Mental and Addiction Health, The Alfred, Melbourne, VIC, Australia
| | | | | | - Suzy Redston
- Mental Health Division, Austin Health, Austin Health, Heidelberg, VIC, Australia
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Collins SE, Goldstein SC, King VL, Orfaly VE, Gu J, Clark A, Vess A, Lee G, Taylor EM, Fentress T, Braid AK, Clifasefi SL. Characterizing components of and attendance at resident-driven Housing First programming in the context of community-based participatory research. J Community Psychol 2021; 49:1376-1392. [PMID: 33301627 PMCID: PMC8190162 DOI: 10.1002/jcop.22491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 09/16/2020] [Accepted: 11/04/2020] [Indexed: 06/12/2023]
Abstract
AIMS This secondary study characterized components of and engagement in the life-enhancing alcohol-management program (LEAP), which is resident-driven housing first programming. METHODS We used a process akin to conventional content analysis to operationalize the LEAP according to its component activities. We used generalized linear modeling to identify predictors of LEAP activity participation and to predict alcohol and quality-of-life outcomes from participation in specific LEAP activities categories. RESULTS Overall, 86% of participants attended at least one LEAP activity, which comprised three categories: administrative leadership opportunities, meaningful activities, and pathways to recovery. Employment status alone predicted LEAP activity attendance: Employed residents attended 88% fewer LEAP activities than unemployed residents. Participants who sought out more pathways to recovery activities were more likely daily drinkers and more impacted by alcohol-related harm. Those engaging in administrative leadership opportunities were overall less impacted by alcohol use and had a higher quality of life generally, and their alcohol outcomes further improved over time. CONCLUSIONS Programming developed with Housing First residents was well-attended but could be made more inclusive by including evening programming to accommodate residents employed full time and engaging more severely impacted participants in administrative leadership activities, where the greatest benefits of programming were seen.
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Affiliation(s)
- Susan E Collins
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Silvi C Goldstein
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Victorio L King
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Victoria E Orfaly
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Jingyan Gu
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Alex Clark
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Alexander Vess
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Gary Lee
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Emily M Taylor
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Taurmini Fentress
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Ashley K Braid
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Seema L Clifasefi
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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Selick A, Langill G, Cheng C, Addington D, Archie S, Butt S, Durbin J. Feasibility and acceptability of a volunteer peer fidelity assessment model in early psychosis intervention programmes in Ontario: Results from a pilot study. Early Interv Psychiatry 2021; 15:480-485. [PMID: 32232930 DOI: 10.1111/eip.12961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 01/14/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022]
Abstract
AIM Fidelity monitoring can support high-quality service delivery but is resource-intensive to implement. A fidelity assessment model utilizing volunteer assessors was trialled as a low-cost strategy for conducting fidelity assessments. This article reports on the acceptability and feasibility of this model. METHODS Twenty volunteer assessors were trained to conduct fidelity assessments in nine Early Psychosis Intervention programmes across Ontario, Canada. Assessments were conducted using the First-Episode Psychosis Services Fidelity Scale based on a 2-day site visit, during which assessors interviewed staff, clients and families; reviewed charts; observed a team meeting and reviewed programme materials. The model was evaluated based on assessor focus groups, programme interviews, consensus meeting data and time-tracking logs. General inductive analysis was used to code and synthesize qualitative data. Quantitative data were aggregated and summarized. RESULTS Participant feedback was positive and indicated that use of peer assessors and the in-person site visit added value to the process. The model was perceived to provide valuable information to support internal quality improvement efforts. Assessors reported direct benefits from participating, including networking and learning opportunities. Key challenges were the high time demand on assessors and turnover in the assessor team. CONCLUSIONS The volunteer peer fidelity model was perceived to be a valuable improvement process by participants, but the high cost and reliance on ongoing volunteerism makes its sustainability uncertain. Next steps may include exploring remote assessment strategies or direct payments, although these strategies risk reducing the acceptability, and therefore uptake, of the assessment.
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Affiliation(s)
- Avra Selick
- Provincial System Support Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gordon Langill
- Canadian Mental Health Association, Haliburton Kawartha Pine Ridge Branch, Ontario, Canada
| | - Chiachen Cheng
- Department of Psychiatry, Northern School of Medicine, Thunder Bay, Ontario, Canada
| | - Donald Addington
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Archie
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Shannel Butt
- Canadian Mental Health Association, Elgin Branch, St Thomas, Ontario, Canada
| | - Janet Durbin
- Provincial System Support Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Semborski S, Redline B, Rhoades H, Henwood B. Provider perspectives of housing programs for young adults experiencing homelessness. Child Youth Serv Rev 2020; 112:104898. [PMID: 33041411 PMCID: PMC7543879 DOI: 10.1016/j.childyouth.2020.104898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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10
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Canham SL, Wister A, O'Dea E. Strengths, weaknesses, opportunities, and threats to housing first in Metro Vancouver. Eval Program Plann 2019; 75:69-77. [PMID: 31121391 DOI: 10.1016/j.evalprogplan.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To understand the experience of Metro Vancouver's Homelessness Partnering Strategy-funded Housing First program and how it is functioning from the perspective of a representative sample of providers and clients who deliver and receive HF services. METHODS Thirty-four clients and providers who currently or formerly delivered HF in Metro Vancouver participated in one-on-one interviews (n = 26) or focus groups (n = 8) between March and April 2017 and data were thematically analyzed. RESULTS Strengths of the HF program included: the ability to transition persons from the street into housing with individualized service supports and, in certain cases, with 12-month rent subsidies, household goods, and connection to community resources. Identified program weaknesses were: eligibility criteria, limited rent subsidy funds, limited provider capacity, and workload burden. Suggested opportunities to improve HF were: streamlining federal and provincial reporting and rent subsidy systems and building friendly landlord networks. Potential threats to HF described were: limited affordable housing, stigma and discrimination toward clients, inadequate income assistance, and limited opportunity for cross-sector collaboration. CONCLUSIONS The delivery of HF in regions that have limited affordable housing presents unique challenges. Recommendations are provided to improve HF practice and policy in these contexts.
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Affiliation(s)
- Sarah L Canham
- Gerontology Research Centre, Simon Fraser University, 2800 - 515 W. Hastings, Vancouver, BC, V6B 5K3 Canada.
| | - Andrew Wister
- Gerontology Research Centre, Simon Fraser University, 2800 - 515 W. Hastings, Vancouver, BC, V6B 5K3 Canada; Department of Gerontology, Simon Fraser University, 2800 - 515 W. Hastings, Vancouver, BC, V6B 5K3 Canada.
| | - Eireann O'Dea
- Department of Gerontology, Simon Fraser University, 2800 - 515 W. Hastings, Vancouver, BC, V6B 5K3 Canada.
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Henwood BF, Harris T, Woo D, Winetrobe H, Rhoades H, Wenzel SL. Availability of comprehensive services in permanent supportive housing in Los Angeles. Health Soc Care Community 2018; 26:207-213. [PMID: 28984074 PMCID: PMC6277053 DOI: 10.1111/hsc.12510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 05/13/2023]
Abstract
Studies have often described a specific model or models of permanent supportive housing (PSH), yet few studies have systematically examined what services are typically offered to PSH tenants in any given service system and how those services are offered. Using telephone surveys from 23 PSH agency supervisors and qualitative data collected from 11 focus groups with 60 frontline providers and 17 individual interviews with supervisors from a subset of surveyed agencies-all of which were completed between July 2014 and December 2015-the goal of this study is to better understand what services are being offered in PSH organisations located in Los Angeles and what barriers frontline providers face in delivering these services. Survey findings using statistical frequencies suggest the existence of robust support services for a high-needs population and that single-site providers may offer more services than scatter-site providers. Qualitative thematic analysis of interview and focus group transcripts suggests services may be less comprehensive than they appear. If PSH is to be regarded as an intervention capable of more than "just" ending homelessness, further consideration of the provision of supportive services is needed.
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Affiliation(s)
- Benjamin F Henwood
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Taylor Harris
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Darlene Woo
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Hailey Winetrobe
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Harmony Rhoades
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Suzanne L Wenzel
- School of Social Work, University of Southern California, Los Angeles, CA, USA
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12
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McPherson P, Krotofil J, Killaspy H. What Works? Toward a New Classification System for Mental Health Supported Accommodation Services: The Simple Taxonomy for Supported Accommodation (STAX-SA). Int J Environ Res Public Health 2018; 15:E190. [PMID: 29364171 PMCID: PMC5858263 DOI: 10.3390/ijerph15020190] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/15/2018] [Accepted: 01/19/2018] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Peter McPherson
- Division of Psychiatry, University College London (UCL), London W1T 7NF, UK.
| | - Joanna Krotofil
- Division of Psychiatry, University College London (UCL), London W1T 7NF, UK.
| | - Helen Killaspy
- Division of Psychiatry, University College London (UCL), London W1T 7NF, UK.
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13
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Abstract
American researchers have led the world in developing, evaluating, and disseminating evidence-based psychiatric rehabilitation practices for people with serious mental illness. Paradoxically, however, the USA lags behind most industrialized nations in providing access to high-quality mental health and psychiatric services. This essay examines several evidence-based practices developed in the USA, the spread of these practices, the barriers to ensuring availability to people who could benefit from these services, and some promising directions for overcoming the barriers. Factors influencing the growth and sustainment of effective client-centred practices include the availability of adequate and stable funding, committed leadership, and the influence of vested interests. Two strategies for promoting the spread and sustainment of well-implemented evidence-based practices are the adoption of fidelity scales and learning communities.
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Affiliation(s)
- G. R. Bond
- Westat Inc, Health Studies Sector, Rivermill Commercial Center, 85 Mechanic St., Lebanon, New Hampshire 03766, USA
| | - R. E. Drake
- Westat Inc, Health Studies Sector, Rivermill Commercial Center, 85 Mechanic St., Lebanon, New Hampshire 03766, USA
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14
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Dickson-Gomez J, Quinn K, Bendixen A, Johnson A, Nowicki K, Ko Ko T, Galletly C. Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes. Am J Orthopsychiatry 2017; 87:414-424. [PMID: 28301175 DOI: 10.1037/ort0000232] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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
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Affiliation(s)
| | | | | | | | | | - Thant Ko Ko
- Institute for Public and Community Health, Medical College of Wisconsin
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15
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Nelson G, Caplan R, MacLeod T, Macnaughton E, Cherner R, Aubry T, Méthot C, Latimer E, Piat M, Plenert E, McCullough S, Zell S, Patterson M, Stergiopoulos V, Goering P. What Happens After the Demonstration Phase? The Sustainability of Canada's At Home/Chez Soi Housing First Programs for Homeless Persons with Mental Illness. Am J Community Psychol 2017; 59:144-157. [PMID: 28134440 DOI: 10.1002/ajcp.12119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This research examined the sustainability of Canada's At Home/Chez Soi Housing First (HF) programs for homeless persons with mental illness 2 years after the end of the demonstration phase of a large (more than 2000 participants enrolled), five-site, randomized controlled trial. Qualitative interviews were conducted with 142 participants (key informants, HF staff, and persons with lived experience) to understand sustainability outcomes and factors that influenced those outcomes. Also, a self-report HF fidelity measure was completed for nine HF programs that continued after the demonstration project. A cross-site analysis was performed, using the five sites as case studies. The findings revealed that nine of the 12 HF programs (75%) were sustained, and that seven of the nine programs reported a high level of fidelity (achieving an overall score of 3.5 or higher on a 4-point scale). The sites varied in terms of the level of systems integration and expansion of HF that were achieved. Factors that promoted or impeded sustainability were observed at multiple ecological levels: broad contextual (i.e., dissemination of research evidence, the policy context), community (i.e., partnerships, the presence of HF champions), organizational (i.e., leadership, ongoing training, and technical assistance), and individual (i.e., staff turnover, changes, and capacity). The findings are discussed in terms of the implementation science literature and their implications for how evidence-based programs like HF can be sustained.
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Affiliation(s)
| | | | | | | | | | - Tim Aubry
- University of Ottawa, Ottawa, ON, Canada
| | - Christian Méthot
- McGill University, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Eric Latimer
- McGill University, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Myra Piat
- McGill University, Douglas Mental Health University Institute, Montreal, QC, Canada
| | | | | | - Sarah Zell
- University of Winnipeg, Winnipeg, MB, Canada
| | | | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Paula Goering
- Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
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16
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Abstract
This mixed-method study used administrative data from 68 supportive housing programs and evaluative and qualitative site visit data from a subset of four forensic programs to (a) compare fidelity to the Housing First model and residential client outcomes between forensic and nonforensic programs and (b) investigate whether and how providers working in forensic programs can navigate competing Housing First principles and criminal justice mandates. Quantitative findings suggested that forensic programs were less likely to follow a harm reduction approach to substance use and clients in those programs were more likely to live in congregate settings. Qualitative findings suggested that an interplay of court involvement, limited resources, and risk environments influenced staff decisions regarding housing and treatment. Existing mental health and criminal justice collaborations necessitate adaptation to the Housing First model to accommodate client needs.
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Affiliation(s)
- Liat S Kriegel
- School of Social Work, University of Southern California, Montgomery Ross Fisher Building, Los Angeles, CA, 90089-0411, USA.
| | - Benjamin F Henwood
- School of Social Work, University of Southern California, Montgomery Ross Fisher Building, Los Angeles, CA, 90089-0411, USA
| | - Todd P Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, 92093, USA
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Abstract
Over the last 5 years, community policies in response to homelessness have shifted toward offering permanent housing accompanied by treatment supports, without requiring treatment success as a precondition. The US Department of Veterans Affairs (VA) has embraced this "Housing First" approach. A 2013 report sounds a contrarian note. In a 16-person quasi-experimental study, 8 veterans who entered VA's permanent supportive housing did poorly, whereas 8 veterans who remained in more traditional treatment did well. In this commentary, we suggest that the report was problematic in the conceptualization of the matters it sought to address and in its science. Nonetheless, it highlights challenges that must not be ignored. From this report and other research, we now know that even more attention is required to support clinical recovery for Housing First clients. Successful implementation of Housing First requires guidance from agency leaders, and their support for clinical staff when individual clients fare poorly.
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18
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Macnaughton E, Stefancic A, Nelson G, Caplan R, Townley G, Aubry T, McCullough S, Patterson M, Stergiopoulos V, Vallée C, Tsemberis S, Fleury MJ, Piat M, Goering P. Implementing Housing First Across Sites and Over Time: Later Fidelity and Implementation Evaluation of a Pan-Canadian Multi-site Housing First Program for Homeless People with Mental Illness. Am J Community Psychol 2015; 55:279-291. [PMID: 25772023 DOI: 10.1007/s10464-015-9709-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article examines later fidelity and implementation of a five-site pan-Canadian Housing First research demonstration project. The average fidelity score across five Housing First domains and 10 programs was high in the first year of operation (3.47/4) and higher in the third year of operation (3.62/4). Qualitative interviews (36 key informant interviews and 17 focus groups) revealed that staff expertise, partnerships with other services, and leadership facilitated implementation, while staff turnover, rehousing participants, participant isolation, and limited vocational/educational supports impeded implementation. The findings shed light on important implementation "drivers" at the staff, program, and community levels.
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19
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van den Berk-Clark C. The Dilemmas of Frontline Staff Working with the Homeless: Housing First, Discretion, and the Task Environment. Hous Policy Debate 2015; 26:105-122. [PMID: 26900305 PMCID: PMC4755917 DOI: 10.1080/10511482.2014.1003142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This paper examines staff discretion in permanent supportive housing facilities run by a nonprofit agency claiming to use a housing-first approach. Field observation, archival data, and individual and group interviews with staff and clients were examined to better understand agency processes involved in intake, sanctions, and disposal of clients to evaluate housing-first fidelity. In their day-to-day interactions with clients, frontline workers' discretion is affected by working conditions such as lack of resources and heavy workloads, as well as by demands placed on the agency by members of the its task environment. Implications for housing-first programs and homeless clients are discussed.
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Affiliation(s)
- Carissa van den Berk-Clark
- Washington University School of Medicine, St. Louis Missouri, USA; Department of Veteran Affairs, VA St. Louis Healthcare System, St. Louis, Missouri, USA
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20
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Kertesz SG, Austin EL, Holmes SK, Pollio DE, Schumacher JE, White B, Lukas CV. Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing. J Gen Intern Med 2014; 29 Suppl 4:835-44. [PMID: 25355085 DOI: 10.1007/s11606-014-3025-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. OBJECTIVE Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals. DESIGN This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs). PARTICIPANTS Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012. APPROACH Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM). KEY RESULTS Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation. CONCLUSION Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.
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Gilmer TP, Katz ML, Stefancic A, Palinkas LA. Variation in the implementation of California's Full Service Partnerships for persons with serious mental illness. Health Serv Res 2013; 48:2245-67. [PMID: 24138021 DOI: 10.1111/1475-6773.12119] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study examined variation in the implementation of California's Full Service Partnerships (FSPs), which are supported housing programs that do "whatever it takes" to improve outcomes among persons with serious mental illness who are homeless or at risk of homelessness. DATA SOURCES/SETTING Ninety-three FSPs in California. STUDY DESIGN A mixed methods approach was selected to develop a better understanding of the complexity of the FSP programs. The design structure was a combined explanatory and exploratory sequential design (qual→QUAN→qual) where a qualitative focus group was used to develop a quantitative survey that was followed by qualitative site visits. The survey was used to describe the breadth of variation based on fidelity to the Housing First model, while the site visits were used to provide a depth of information on high- versus low-fidelity programs. PRINCIPAL FINDINGS We found substantial variation in implementation among FSPs. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing. CONCLUSIONS There remains room for improvement in the recovery-orientation of FSPs. Fortunately, we have identified several processes by which program managers and counties can increase the fidelity of their programs.
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Affiliation(s)
- Todd P Gilmer
- Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA
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