George Mihalakakos, BA Peer Support Worker – CAMH Sandra Cushing, MSW

1. Developing high support housing: How hospital-community partnerships are creating pathways to community in Toronto George Mihalakakos, BA Peer Support Worker – CAMH Sandra Cushing, MSW Advanced Practice Clinician – CAMH Sean Kidd, Ph.D., CPRP Psychologist – CAMH September 21st, 2010

2. Describing partnership • Our goals for this workshop: • Cover a brief overview of history and key concepts of supported housing • Describe some models by which hospital and community providers can create high support housing units, including the preliminary outcomes of one such partnership • Briefly discuss evaluation in this context • Have a conversation in which we can learn from one another how to move this agenda forward in the Canadian context • What we will be unable to accomplish in this time: • Provide extensive coverage of the supported/ive housing literature

3. Housing for people with severe mental illness: A 60 year old (at least) conversation

4. Housing and Mental Illness History in the Literature: The Coles Notes Version • In general, care prior to the 1950s documents long term hospitalization • Mid 1950s: Deinstitutionalization • Nursing homes, board and care, halfway houses, etc. • Outcomes by the mid-late1980s: Back wards in the community • Recommendations: Reform and the housing continuum • 1980s: Advent of the Housing Continuum • Systems with levels of care • Challenge with implementation • The Latest Development: Supported Housing • Permanent housing with wraparound supports (multidisciplinary) • Models have emerged such as ‘housing ready’ requiring service involvement and ‘housing first’ using a harm reduction approach and not requiring service involvement • (some authors contrast with ‘supportive’ housing – typically congregate settings)

5. When people are provided with a decent place to live, opportunities with which to work on recovery goals, and reasonable supports you see: • Greater housing stability and less hospitalization • Reduction in symptoms, alcohol and substance use • Increased employment • Satisfied people • Little difference in outcomes seen comparing continuum vs. supported housing other than satisfaction • Both approaches better than non-model housing (boarding homes with no support; homelessness; hospitalization) • Better outcomes – linked to higher quality housing, buildings with fewer units, newer neighbourhoods, mixed race neighbourhoods • Money saved: $500-800/day in hospital vs. $250-400/day in housing + supports • Challenges seen in implementation of supported housing (variability) • Challenges in research: variability; poorly articulated models; lack of comparability

6. The Ontario Context

7. Housing in Ontario – The Options • Range of custodial, supportive, and supported housing settings • 6300 units managed by 74 community organizations (as of 2007) • Overemphasis on supervised congregate settings – in a 1999 study it was found that only 14% of those in these settings require this type of support • Variably not enough housing stock in some settings and not enough support in others • Long waits in many settings and jurisdictions • Challenges in rural settings

8. Alternative Level of Care: A Pressing Need Area • 48% of long stay psychiatric inpatient clients could have their needs successfully met in the community (true of CAMH) • This represents 12% of all patient days in Ontario, for physical or mental health conditions

9. So, why so many people in hospital who don’t need to be there? • Staff attitudes and expectations • Poor bridging to the community • Family refusal of placement options • Lack of high support housing

10. The Challenge for the CAMH Schizophrenia Program • Approximately 40% of our clients are ALC • Not enough high support housing • How did it begin?

11. The Partnership at 90 Shuter St. • CAMH Schizophrenia Program • Bridging from the inpatient unit • Case Management • Outpatient Psychiatry • Primary Care • Peer Support • Homes First • Bricks & Mortar • Access to Community • Pilot Place • On-site 24/7 staff

12. The Setting • Neighbourhood • Formerly very rough, now moderate • Ready access to amenities • Ready access to parks, cultural and rec centres • Building • Hardest to house, most formerly homeless • 9 floors • Some active substance users • Security • 9 units, shared space, high quality

13. Who Moved In • August, 2009 • 5 long stay clients (8 years avg) • 3 men, 2 women • Schizophrenia • January, 2010 • 4 more clients • 2 men and 2 women

14. Capturing How it is Going • Staff & Management (all) • Interviews • Recovery Self-Assessment • Wilder Collaboration Factors Inventory • Residents (7/9) • Interviews • Recovery Self-Assessment • WHO Quality of Life Brief • Hospital & Service Use • Economic Analysis

15. Findings – Recovery Self Assessment

16. Manager RSA Ratings

17. Wilder Collaboration Inventory Findings • Generally agreed upon weaknesses: • Informal relationships and communication links; open and frequent communication • Generally agreed upon strengths • Good cross section of partners; shared vision; motivated by common purpose • Differences of opinion • Compromise; pace; resources available

18. WHO – Quality of Life

19. Key Findings from the Stats • There is some discrepancy in perspective on the degree of recovery orientation • Several groups think that the service could be more recovery-oriented, particularly around consumer involvement and diversity of treatment options. • While all agree that the necessary partners are involved and have a shared vision, there is a need for better communication (particularly informal communication) and some attention to agreement around compromise, pace, and resources • Quality of life is fairly good, but could see some improvement (particularly quality of social relationships)

20. Qualitative Interviews: Clients • The quality of the apartment and the food is very good • Two commented that they found the neighbourhood somewhat unsafe, but were not overly afraid for their safety • A general agreement about getting along well with the other residents and also generally liking all of the staff who are involved at a personal/relationship level

21. Qualitative Interviews – Clients • Dislike registered about a range of restrictions: • Access “I can’t really get involved [in church groups] because we have to be in by 9:00” “I want to go to restaurants in the morning for coffee, but I can’t. I’ve got to stay here. It’s kind of depressing, because you can see more people in the morning.” • In charge of finances “I’m a bus boy. [You’re making a bit of money doing that?] I guess so, but they cash my cheques. They never give me money.”

22. Client Goals and Sources of Strength • “It’s very nice living here, very beautiful. I’ve got my own room. I want to get a job now. I’m just so comfortable that I want to get a job.” • “I want to make my own meals. I want to go to work.”

23. Client Change • “I’m talking more…I haven’t done much of that in my life.” • “I’m adapting to the community. It takes time.” • “I try to go to church every day. It makes me feel better. I make lots of friends at church.” • “I’m doing a little bit better. I get to go out and walk around.” • “I feel better here. You get your marbles back. You get a bit loony over at Queen St.”

24. Staff and Manager Perspectives – Client Gains “I think it is a home.” • People are housed • “Well I think it is working well in that the people are still housed. Ultimately, that’s the best measure.” • People are more social • “It was really amazing. We [saw] two of the clients who were very seclusive on the IRU and I was totally blown away…they created a bond with one another and talked about that bond.” • “They all have friends here.” • Greater autonomy – “They are less dependent there” • “They were very unmotivated and didn’t bother to go out [while on the unit], but there they go to church, go out to dinner, and they really had activities that they were involved in….someone else is going swimming on a regular basis.” • Confidence • “I see them more confident…more comfortable and open…just seeing the increase in self-esteem and confidence was great.”

25. Staff and Management on the Services Provided • Facilitating engagement in treatment • “We don’t allow people to miss treatments. As much as possible, nobody misses appointments.” • Bridging from the inpatient unit • Daily contact for 3 weeks, tapering back over 3 months • “Clients like it because they didn’t know us that well, or at all. They were so happy when [staff] would come and visit.” • Family Involvement • “We celebrate Christmas, Mother’s Day, Family Day, and we usually call family. For one individual, 9 family members came to an event….it makes a big difference.” • Independence skills • “We break it [e.g., washing dishes] into steps, so it’s clear.” • “We always try to engage them in terms of taking them out into the community…we encourage who we can.” • “Right from the beginning we have taken them to safe spots that we know of downtown…eventually they know certain spots in the neighbourhood and feel confident to go on their own.” • Peer Support – recovery groups

26. Peer Support • Peer support has been present at CAMH since October of 2008 • My goal on my unit on the IRU (Integrated Rehabilitation Unit) has been to promote further independence and autonomy for clients • Other tasks include support around interpersonal skills, assertiveness and communication skill development. Also, involves self-advocacy, education around recovery and providing an outlet for clients wanting to express their concerns and challenges • One way I would describe my goal is helping clients find their voice • In addition to the above activities, another of my main purposes at 90 Shuter is to help facilitate community integration for clients • One of the ways I do this is by bridging and connecting clients to resources and each other

27. A critical tension: Autonomy vs. Safety • Differing service philosophies • Autonomy: • “Not having that accessibility to go and come as they feel…that in a sense is taking them a couple of steps back.” • “There needs to be more integration, openness to community, and utilizing the resources available in the community.” • “It’s still a semi-hospital setting.” • “I want to encourage clients to be on their own a little bit more.”

28. A critical tension: Autonomy vs. Safety • Safety • “We’ve had to defend them a lot of times. Some of them are quite innocent. Some of them are just targets to be taken advantage of and we are not going to let that happen…there is a lot of criminal activity.” • “I interviewed all of the residents when we first got them and even though the workers thought they should have metro passes, so they could travel about the city, when you actually talk to them they don’t want to go anywhere.” • “I primarily believe in safety.”

29. Additional Comments • More programming around physical health/fitness • No staff presence during Peer Support groups • Questions around duplication of services and room for efficiency (e.g., around obtaining medications) • Scheduling challenges (distance to GPs; outpatient clinic) • Need for better integration (staff-staff; resident-building resident; resident-community service; resident-other camh clients for programming)

30. Additional pieces of the evaluation in progress: • Economic Analysis (though previous findings suggest a difference of about $100 vs. $600/day) • CAMH service use (though we know now that no one has been rehospitalized) • Family/support perspectives

31. In Sum • This partnership is strong and built from highly motivated groups with a shared vision about providing feasible high support housing opportunities in the future • The clients at 90 Shuter have experienced growth in many areas, have maintained their housing, and have not been back to hospital • There are several areas, including perspectives regarding the level and type of support, communication, and service integration that, if addressed, could lead to a stronger partnership and more effective service

32. Considerations for Next Steps • Building upon the strength of a shared vision and strong partnership to allow for more opportunities for informal staff interactions and communication • A movement in treatment and care towards an emphasis on greater autonomy and community integration – creating individualized plans and providing necessary supports • Looking for ways of integrating CAMH outreach (outpatient staff; psychiatry; groups held with other clients) • Consideration of additional psychosocial rehabilitation treatment models (Expanded peer support involvement; WRAP groups; Supported Employment and education strategies; fitness-oriented groups and interventions with Recreation Therapy; smoking cessation treatment) • Removing the staff presence when Peer Support groups are held

33. Other models under consideration • Consideration of other community partners in different locations • Different settings (e.g., bachelor apartments) • Variation in level of support (e.g., on-call staffing overnight)

34. For Discussion • In small groups: • Describe your context with respect to housing (both problems and strengths) • Discuss models that have worked and/or what might be feasible and effective • Where does the field, as a whole, need to go (discuss policy, models, service systems) (*please keep track of themes for large group discussion*)