Implementing Housing First in Five Cities

1. Implementing Housing First in Five Cities Paula Goering May 30 , 2013

2. Outline for today Overview of Project Design Balancing Fidelity to program model and adaptation to local circumstances National and site level findings re one year housing outcomes Identification of critical ingredients .

3. Federal Budget Announcement • Homelessness Partnering Strategy • Economic Action Plan 2013 proposes $119 million per year over five years, nearly $600 million in total, to the Homelessness Partnering Strategy using a “Housing First” approach. • Building on the successful At Home/Chez Soi project, the Government will continue to work in partnership with provinces and territories, communities, the private sector and other stakeholders, such as the Federation of Canadian Municipalities, to reduce homelessness. Over the coming months, the Minister of Human Resources and Skills Development will work with Government partners at the community level to confirm the implementation details of this approach.

4. Research demonstration objectives Policy shift – Evidence-informed investments in Housing First to address chronic homelessness among people with serious mental illness Opportunity to create lasting system change Federal/provincial/territorial/municipal collaborations Scalable investment opportunities for all levels of government moving forward

5. At Home/Chez Soi Project Overview In 2008 the Federal government allocated $110million At Home/Chez Soi is: • the largest study of its kind in the world • providing evidence about what services and systems best help people experiencing serious mental health issues and homelessness • Housing First model • implemented in: Vancouver, Winnipeg, Toronto, Montreal, Moncton • Funding – 85% services / 15% research

6. Housing First • Housing is immediate and permanent • Recovery & choice emphasized • Housing is primarily scattered site, private market • Supports include guaranteed rent subsidies – clients pay 30% • Additional services (>1 visit) are voluntary • No readiness/maintenance conditions • Tenancy rights • Draws upon Pathways to Housing and Streets to Homes program models

7. + Housing First Approach of At Home / Chez Soi Subsidized Housing ACT or ICM

8. Characteristics of the housing model Slightly different housing models used in each site to reflect local context All housing teams responsible to engage landlords and procure housing; help manage available housing stock Variation in size of teams and organizational structure of teams; interaction with service teams and participants e.g. division between roles (Vancouver) or joint/shared roles (Montreal) Housing in At Home/Chez Soi Housing Models

9. Focusing the FrameA Participant Photography Project My Kitchen _____________________________________ I love to cook. On the street it's hard to get a decent meal. Now my fridge is full and I can choose what and when I eat. I'm so much healthier now, and I get so much satisfaction in doing something I love to do. I can even invite people over for a meal. Beats the hell out of a food kitchen. View from my Window ____________________________________ I am so grateful for this view. I am also grateful to not have anyone able to knock on my window at all hours of the night. I have some sense of safe.

10. Implementation of Housing First • National and local training events • Technical assistance visits • Communities of practice • Fidelity measurement • Quality assurance

11. Research Design • Pragmatic, multi-site, randomized, mixed methodsfieldtrial • Effectiveness and costeffectiveness of Housing First Model in Canadian contexts • Model beingtestedattwolevels of intensity High needs =ACT Moderateneeds = ICM

12. Research Design (cont’d) • Randomized to Housing First (HF) or TAU • Each site has third arm • Comparisons to care as usual in all cities • Outcome data collected at baseline, 6, 12, 18, & 21 months • Two fidelity assessements and formative evaluations • Qualitative data collected on subgroup of participants at baseline and 18 months

13. Target Population • Adults (age 18 (19 in Vancouver)) • Homeless (absolutely or precariously housed) • Presence of a serious mental health issue w/ or w/o co-occurring substance use disorder • Over-sampling to ensure sufficient number of women (min. 20%) • Total planned sample size 2205 (1255 exp and 1080 TAU)

14. Vancouver Site • Unique context during planning and development was Olympic Games • Outcomes of individuals with serious addictions e.g. injection drug use • Intervention third arm includes comparison to a congregate setting

15. Toronto Site • Focus is on needs of diverse ethnocultural groups • Intervention includes modifications for different ethnic groups • Anti-racisim/anti-oppression framework • Also chronic physical illnesses, access to primary care • Consumers have been very involved

16. Moncton Site • Intervention will blend high and moderate need services in one • “flexible supports” • Focus is on models for smaller cities • Also an interest in homelessness in rural areas

17. Lessons: Housing Market Primer Source: Rental Market Report: Canadian Highlights; CMHC Fall 2011

18. Lessons: Housing Market Primer Source: Rental Market Report: Canadian Highlights; CMHC Fall 2011

19. Key Findings from Interim Report • Housing First makes better use of public dollars, especially for those who are historically high users of service. • Individuals who have not been well-served by our current approach, and who have remained homeless for years, are being successfully housed in adequate, affordable, and suitable settings. • People with mental health issues can live independently in the community with the right supports. • There is strong support for continued investment. • Rich pool of policy relevant knowledge will assist with decision making about future investments and scaling up.

20. Early Project Findings Over 900 people currently housed in adequate, affordable, suitable settings Stable living conditions contribute to a shift from the frequent use of inappropriate and expensive services • At Home/Chez Soi saved the system a net average of $9,390 for those who had a high use of services “High Users”  Housing First has the potential to provide system-wide cost offsets. • Individuals receiving Housing First saved the system a yearly average of $2,184 per person in costs related to inpatient stays – this savings was even greater for the “high user” sub-group Canada can (and is) implementing Housing First Benefits cross a range of sectors (health, social services, criminal justice)

21. Residential status of participants Homeless History • Average lifetime homeless=5 years • First episode more than one year before study entry=77% • Over 900 people housed in adequate, affordable settings • At 12 months, time spent in stable housing: Housing First (HF) = 80%; Treatment As Usual (TAU) = 33%. • Over 65% of HF housed are still in first apartment at end of year 3. Landlords as partners have helped us achieve this • Have over 260 private landlords involved across five cities. • Makes good business sense. • Want to contribute to solving homelessness for their communities.

22. Time spent in stable housing over year one

24. Mixed methods implementation evaluation External Quality Assurance team (20 fidelity reports) Round 1 ratings:84 staff interviews, 10 consumer focus groups, and 100 chart reviews Round 2 ratings: 89 staff interviews, 11 consumer focus groups, and 102 chart reviews Qualitative implementation (10 site & 2 cross-site reports) Round 1 ratings:72 key informant interviews, 35 focus groups with 211 participants Round 2 data sources: 36 key informant interviews, 17 staff focus groups, and 57 interviews with landlords and caretakers.

25. Summary of fidelity rating results 10 programs rated on 38 fidelity items in 5 domains Early implementation and one year later Overall, strong fidelity to the Housing First model (program ingredients rated above 3 on a 4-point scale) 71% round one 78 % round two Variation at individual program level and by service delivery type, e.g. more challenges for ICM re service array domain It is possible to tailor Housing First to different city contexts and still remain true to the program model

26. Implementing At Home/Chez Soi Strengths: partnerships, housing and re-housing participants, and specialist staff providing valuable services. Challenges :staff turnover, the scatter-site model of housing not working for everyone, participant isolation, the need to further enhance peer support and consumer participation, housing/re-housing issues, and the need to develop more vocational and educational opportunities for participants.

27. Critical Ingredients for Success Round 1 Barrier free housing Recovery philosophy High quality, multi faceted care delivered by well trained staff Round 2 Staff values re acceptance of participants Team communication Consumer choice Re-housing Positive Landlord and caretaker engagement

28. Lived experience http://athome.nfb.ca/#/athome/video/18

29. Lessons: Engaging landlords • Over 260 private landlords and property management companies involved in the project • Significant work to engage landlords and sustain their involvement over time • Can be challenging to keep landlords engaged when dealing with evictions, damages, etc. • Strategies to engage include: • offering supports and services to landlords • holding landlord lunches • recognizing landlord contribution

30. Re-housing Significant time and effort goes into supporting the few participants that need to be re-housed Re-housing is an expected part of Housing First Across the project, participants have been re- housed 400 times Evictions/risk of evictions common reason for re-housing Teams work with participants when they move to determine what will be different in the new housing Lessons: Sustaining Housing

31. The Final Deliverable: Report and dissemination At Home/Chez Soi ends March 31, 2013 Final data cleaning and analysis Formulation of policy recommendations – policy forum – October 2013 Final reports December 2013 Ongoing dissemination of findings through MHCC’s Knowledge Exchange Center and ongoing publications and local KE activities

32. Further Scaling up Activities Development of a HF toolkit Partnership with Provincial and National Housing and Homelessness Organizations (thinktanks, PHSI and SHERC grant applications) Consultations to jurisdictions interested in implementing or scaling-up of Housing First approaches; Ongoing engagement with local and national media and, Continued development of Here at Home an interactive website in partnership with NFB. Applications for further funding to follow up participants post project.

33. Acknowledgements The national At Home/Chez Soi project team: Jayne Barker, PHD (2008-11) and Cameron Keller, MHCC National Project Leads; Paula Goering, RN, PhD, Research Lead and approximately 40 investigators from across Canada and the US. In addition there are 5 site coordinators and numerous service and housing providers as well as persons with lived experience. This research has been made possible through a financial contribution from Health Canada to the Mental Health Commission of CanadaThe views expressed herein solely represent the authors.

34. Thank you! Contact us: Paula Goering paula_goering@camh.net Visit: www.mentalhealthcommission.ca Follow us on: The views represented herein solely represent the views of the presenters. Production of this document is made possible through a financial contribution from Health Canada.