MHCC ‘At Home’ Project in Toronto

1. MHCC ‘At Home’ Project in Toronto

2. Project Overview • Initiated and funded by the Mental Health Commission of Canada. • Multi-site study in 5 cities across Canada: Vancouver, Winnipeg, Toronto, Montreal, Moncton. • Project Team in Toronto: Centre for Research on Inner City Health, St. Michael’s Hospital; City of Toronto - Shelter, Support and Housing Administration Division; and community based service providers. • Purpose: To examine the effectiveness and cost effectiveness of housing and supports for homeless adults with serious mental health issues. • Goal: To create evidence for policy makers about what services and supports work best for this group.

3. Study Design • 560 people will be enrolled in the study in Toronto: • 300 will be assigned to receive supports and housing • 260 will be assigned to “usual care” • Randomized Controlled Trial that will implement and evaluate: • Housing First + Assertive Community Treatment (ACT) v. Usual Care for high needs participants • Housing First + Intensive Case Management (ICM) v. Usual Care for moderate needs participants • Housing First + Ethno-Racial Intensive Case Management v. Usual Care for participants from racialized groups with moderate needs

4. Intervention: Housing First Housing: • No conditions on housing readiness • Self-contained units (mostly private sector, scattered site) • Rental allowance follows the individual Supports: • Recovery oriented. • Treatment is voluntary, individualized • Delivered by community-based agencies  COTA Health, Toronto North Support Services/Community Resource Connections of Toronto, Across Boundaries

5. Research Activities • Participants interviewed periodically for a period of 2 years: • Quantitative survey interviews every 3 months (honorarium provided for each interview between $10 to $30) • Qualitative interviews (honorarium provided) • Data from administrative databases (OHIP, shelter use) • Research Questions: • Housing stability • Health Status • Quality of Life • Functioning • Health care and social system use / costs • Discrimination

6. Participant Eligibility Criteria: 1 • 18 years or older • Homeless (living in shelter or street) • Serious and persistent mental illness • Serious depression, psychosis, PTSD, panic, bi-polar • Based on: documented diagnosis or diagnostic interview or observed behaviour • Concurrent disorder (substance use) is allowed, however, mental illness should be primary issue - not caused by substance use.

7. Participant Eligibility Criteria: 2 • Unmet mental health support needs: not currently enrolled in ICM or ACT or not receiving level of care that they need. • Should require one of these services. • ICM = long-term, outreach (community) based • Legal status in Canada • Willing to live in the City of Toronto • Able to provide informed consent • Encourage referrals from racialized/visible minority groups

8. Recruitment • Referrals to the study are through the research team • Referrals will be sought from the broad continuum of health & social service providers • Self referrals will be re-directed to health/social service providers • Research assistants mobile to meet with potential participants (we’ll come to you) • Recruitment period will take approx. 1 year (enrollment target of 35 people per month)

9. Referral Process: 1 • STEP 1: Identify client(s) who you feel meet the eligibility criteria. • STEP 2: Discuss study with potential participant and obtain permission to make referral. • STEP 3: Complete the referral form and faxed to research team – attn: Vivian Lee. • STEP 4: Pre-screening discussion on phone between research team and referral source.

10. Referral Process: 2 • STEP 5: Phone conversation with Field Coordinator to set time/place of interview. • STEP 6: Face-to-face screening interview with participant (30-45 mins) to determine eligibility. If eligible and willing to participate: • STEP 7: Baseline interview (1-2 hours) to asses level of need followed by randomization to group assignment.

11. Referral Tips: 1 • Make sure individual wants to be part of study. • Don’t play up the supports & housing possibility. • Be honest … or clients may be de-enrolled. • Use Referral Script provided. • Provide documentation if available and if potential participant gives permission.

12. Referral Tips: 2 • Helpful when workers can support the interview process • Accompany potential participant to/be present for interview • De-briefing interview process • Support for participants randomized to ‘usual care’ • Research Assistants may require your input. • Level of need assessment • Service Teams will require your input if participant is randomized to supports/housing

13. Referral Materials • Referral Information for Service Providers • Referral Script • Referral Information for Potential Participants: • Q & A • Referral Form

14. Referral Script • There is a new research project for people who are homeless and have serious mental health issues. The project is evaluating a model of housing and support services that will provide government and other decision makers with evidence about what services work best for homeless people with mental health issues. • If you are eligible and willing to participate in the study, you could receive independent housing and supports for up to 3 ½ years as part of the study. However, there is also a chance that you may not receive housing or supports even if you agree to participate. • In either situation, researchers will want to interview you about your experiences with housing, health care and your physical and mental health status. Some interviews will be very short (about 10 minutes) and others will take about an hour and half. Everyone who participates in the study will be paid a cash honorarium for each interview. • Does this sound like something you’re interested in participating in or learning more about?

15. Referral #1 • Mr. X is a 40 year old man currently staying at shelter Y. • He has a history of housing instability spanning 15 years. • Efforts to house him have repeatedly failed. His most recent stay at shelter Y started two months ago, after he left a boarding home in Parkdale only three weeks into his tenancy. Although followed by the HOP in the past, he was discharged from their service as they could not identify case management goals. • He frequents Sound Times but has not been engaged in case management in over three months. • Mr. X seems to suffer from a serious mental illness, possibly schizophrenia. He has had several admissions to the Centre for Addiction and Mental Health, but no consistent follow up. • He is managing his basic needs but requiires a lot of help managing his income support, and accessing health and social services in the community. • He has taken medications in the past, but it is not clear how consistently he takes his medications now. • He is not particularly interested in seeing doctors, especially psychiatrists, but is open to the possibility of housing and supports.

16. Referral #2 • Mr. Z is a 30 year old man who stays on and off at shelter W for the past 5 years. He couch surfs with friends the rest of the time. He appears interested in securing housing, and requests a referral to the At Home Project. • He is a heavy substance user, and is frequently intoxicated when he sees you. • His behavior is erratic when he uses, but as long as he stays off drugs and alcohol, he is much more organized and able to handle his affairs independently. He spends all of his income support on drugs and alcohol, and this would seem to be the driver of his housing difficulties. • He has had many visits to the ER and these seem to be related to intoxication. • Mr. Z is able to work full time during periods of abstinence, but has not been able to secure gainful employment in the past 6 months.

17. Referral #3 • Ms. W is a 50 year old woman with a history of schizophrenia and possible developmental delay referred from a hospital psychiatric inpatient unit. • She has a long history of housing instability and is currently homeless. Ms. W requires daily medication administration and a lot of support and direction to attend to her self care. Left on her own, she has difficulty accessing meals and her hygiene deteriorates drastically. Her income is managed by the PGT. • She had been residing at a shelter for a few months prior to her admission to hospital. She has had access to a shelter counselor but no other case management. • When approached by the research team, Ms. W appeared surprised and perplexed. She acknowledged she wanted housing but insisted that she was not interested in any other support. Attempts to explain the study to her, in simple terms, were unsuccessful. Ms. W did not appear to understand the information provided to her and indicated that she was not interested in answering any of the questions asked of her.

18. Referral #4 • Y is a 32 year old woman staying at a women's shelter for the past three months. She had been working as an administrative assistant until 2 years ago, but has not been able to secure gainful employment for over a year. • She appears sad and withdrawn and has disclosed to you that she takes medication for depression. She uses marijuana occasionally but this does not appear to be a major issue at present. • Y does not have access to regular medical care and she has not had a PAP smear in many years. She has no income support in place and seems "lost" every time you try to help her access ODSP. She would be interested in exploring educational / re-training opportunities so that she might be better able to compete for a job in the future, but has great difficulty navigating the system and advocating for herself. She is cut off from family and friends and carries a lot of shame for her circumstances.

19. Study Contacts Referrals: Vivian Lee leevivi@smh.ca 416-864-6060 x 3394 General study inquiries: Kate Mason masonk@smh.ca 416-864-6060 x 6513 Principal Investigators: • Stephen Hwang, CRICH, St. Michael’s Hospital • Pat O’Campo, CRICH • Vicky Stergiopoulos, CRICH