Outcome Findings of Canada’s At Home / Chez Soi Housing First Demonstration Program

Tim Aubry, National Research Team, At Home/Chez Soi Project, School of Psychology, University of Ottawa, Ottawa, Ontario, Canada Geoffrey Nelson, National Research Team, At Home/Chez Soi Project, Dept. of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada 9th European Research Conference – Homelessness in Times of Crisis, FEANTSA, Warsaw, Friday, September 19, 2014

/ 2

Overview of Presentation

1. Study design

2. Description of Housing First Interventions

3. Characteristics of participants

4. Outcome findings

5. Costing findings

6. People with additonal needs

/ 3

Study Design

Pragmatic, multi-site, randomized, mixed methods field trial in five sites across Canada (Vancouver, Winnipeg, Toronto, Montreal, & Moncton)

Investigation of effectiveness and cost-effectiveness of Housing First in Canadian contexts

Model being tested with support at two levels of intensity (high needs = ACT) (moderate needs = ICM) vs. usual care

/ 4

At Home/Chez Soi Housing First Approach

+

Subsidized Housing

Support (ACT or ICM)

/ 5

Characteristics of Housing

• No pre-conditions for housing

• Scattered site private market units

• Maximum of 30% of income for rent

• Participants hold their own lease

• Rights and responsibilities as a tenant

/ 6

Types of Support Services

Assertive Community Treatment (ACT): ACT

• Multi-disciplinary team / wrap around service

• Services and crisis coverage are available 24/7

• Staff to client ratio of 1:10

Intensive Case Management teams (ICM):

• Case managers with individual caseloads

• Outreach and coordination with other services

• Teams available 12 hours per day

• Staff to client ratio of 1:15

/ 7

Who is in At Home/Chez Soi?

• 2148 participants

• 1158 in Housing First (HF)

• 990 in Treatment as Usual (TAU)

• Primarily middle-aged

• 32% of participants are women

• 22% of participants identified as being an Aboriginal person

• Typical total time homeless in participants’ lifetimes is nearly 5 years

• All have one or more serious mental health issue

• Majority have a concurrent disorder

• More than 90% had at least one chronic physical health problem

/ 8

Housing Outcomes of participants

Close to 1,000 Canadians with significant histories of homelessness were successfully housed through At Home / Chez Soi

0%

10%

20%

30%

40%

50%

60%

70%

Housed all of the time Housed some of the time Housed none of the time

Percentage of participants housed in the last six months of the study

Housing First TAU

/ 9

Housing: Stability – by Program

Percentage of time housed

/ 10

Housing: Stability – by Site Percentage of time housed

/ 11

Social Outcome Findings

HF participants in both ICM and ACT reported greater improvements than TAU participants in:

Community Functioning

Quality of Life

/ 12

Social Outcomes: Community Functioning

Average post BL differences are SIG

for both ICM and ACT

/ 13

Social Outcomes: Quality of Life

Average post BL differences are SIG

for both ICM and ACT

/ 14

Health Outcome Findings

• Both groups report improvements in:

Substance use

Mental health

• Both groups maintained their physical health

/ 15

HN average intervention cost nationally: $22,257 per person per year

$10 invested in HF for High Need group : Average savings of $9.60

Cost Analysis – High Need Group (ACT)

$-

$15.000

$30.000

$45.000

$60.000

$75.000

$90.000

TAU Housing First TAU Housing First

Baseline 0M to 21/24M

HF

/ 16

HN Group: Major cost offsets are office visits, hospitals, shelters, visits with other providers and jail or prison

Cost Analysis – High Need Group (ACT)

$(5.000)

$(4.000)

$(3.000)

$(2.000)

$(1.000)

$0

Office visits (non-study) Hospital (Physical)

Emergency shelter

Home visits (non-study) Jail/prison

/ 17

$10 invested in HF for Moderate-Need group : Average savings of $3.42

MN average intervention cost nationally: $14,177 per person per year

Cost Analysis – Moderate Need Group (ICM)

- $

10.000 $

20.000 $

30.000 $

40.000 $

50.000 $

60.000 $

TAU Housing First TAU Housing First

Baseline 0M to 21/24M

HF

/ 18

MN Group: Major cost offsets are shelters and SROs, but costs related to office visits to non study providers increase

Cost Analysis- Moderate Need Group (ICM)

$(2.500)

$(2.000)

$(1.500)

$(1.000)

$(500)

$0

$500

$1.000

$1.500Emergency shelter SRO (w support) Office visits (non-study)

/ 19

Cost Analysis – based on Service use (High Users)

- $

50.000 $

100.000 $

150.000 $

200.000 $

250.000 $

TD-TAU TD-HF TD-TAU TD-HF

Baseline 0M to 21/24M

HF

$10 invested in HF for TOP DECILE group : Average savings of $21.72

TD – Top Decile

/ 20

Cost Analysis – based on Service use (High Users)

$(20.000)

$(15.000)

$(10.000)

$(5.000)

$0

$5.000

Hospital (Psychiatric)

Home visits (non-study) Jail/prison

Office visits (non-study)

Hospital (Physical)

Contacts with the police ER Visits

Crisis housing

SRO (w support)

Psychiatric residential program

Major cost offsets are hospitals, home visits, jail/prison office visits

/ 21

Cost Analysis

Overall Cost Analysis

• Housing First costs $17,735 per person per year on average

• Over the 2-year period following participant enrolment HF services resulted in average reductions of $12,073 in service costs per person.

• Thus every $10 invested in HF services saved an average of $6.81.

• The main cost offsets included: hospital (psychiatric), emergency shelter, hospital (physical) and office visits (non-study)

Cost Analysis based on High Service Users

• Among the 10% who prior to study entry had been using the most services, savings are even more dramatic. This group includes both moderate and high need participants (ICM and ACT)

• The intervention cost $19,582 per person per year on average. Over the 2-year period following participant enrolment every $10 invested in HF saved an average of $21.72.

/ 22

People with Additional Needs

• HF worked well for clients with diverse ethnocultural backgrounds and

circumstances. However for a small group of participants (about 13%)

from whom HF as currently delivered did not result in stable housing in

the first year.

• This group tends to have longer histories of homelessness, lower

educational levels, more connection to street-based social networks,

more serious mental health conditions.

• However, these variables although significant were not strong

predictors of encountering housing difficulties in the first year.

• Alternative approaches to addressing the unique needs of these clients

were tried in some cities.

/ 23

Consumer Narrative Sub-sample

Narrative sub-sample comparable to the full sample

• N=197 at 18-months, 10% of the total sample

• No significant differences on more than 50 variables for full and sub-samples

• Participants interviewed at baseline and 18-months

• 10% attrition rate over time, N=219 at baseline

• 13 life domains re: changes – e.g., typical day, education, work, housing

• Each interview coded for life changes – positive, mixed/neutral, negative (Kappa=.77 for inter-rater reliability)

/ 24

Consumer Narrative Sub-sample

Coding example

• Positive life change – “This is the first time, you know, that I’ve had a home… that I actually feel, like I’ve had supportive housing before, but I didn’t feel like I was safe. And, this is the first place like I… feel like I love to go home…I feel so safe. And…being safe is a major issue for me, you know?”

• Mixed/neutral life change – “That’s what life is, cause it’s just like I said, like picking up, losing it all, picking up, losing it all, picking up, losing it all.”

• Negative life change – “They discharged me to a hotel. I left the next day. It was noisy, bug-infested, full of drugs.”

/ 25

Positive, Mixed/neutral, and Negative Life Changes by Site and by Treatment Condition

Site HF – Type of Change TAU – Type of Change

Positive Mixed/neutral

Negative Positive Mixed/neutral

Negative

Moncton 6 (75.0%) 2 (25.0%) 0 (0%) 1 (12.5%) 3 (37.5%) 4 (50.0%)

Montreal 19 (70.3%) 2 (7.4%) 6 (22.3%) 5 (27.7%) 1 (5.6%) 12 (66.7%)

Toronto 15 (71.4%) 3 (14.3%) 3 (14.3%) 6 (50.0%) 2 (16.7%) 4 (33.3%)

Vancouver 12 (48.0%) 12 (48.0%) 1 (4.0%) 6 (33.3%) 9 (50.0%) 3 (16.7%)

Winnipeg 15 (83%) 13 (17%) 0 (0%) 3 (20.0%) 10 (6.7%) 2 (13.3%)

All Sites 67 (61%) 32 (29%) 10 (10%) 21 (30%) 25 (35%) 25 (35%)

Mantel Haenszel χ2=28.5, df=1, p=.0000001

/ 26

Summary of Key Findings

1. Housing First is doable in Canadian cities

2. Fidelity to a Housing First model is essential

3. Housing First can rapidly end homeless

4. Housing First produces other positive outcomes

5. Housing First makes good use of public dollars

6. A small minority of individuals present with additional needs and fail to settle in HF

/ 27

Acknowledgements

This presentation: Carol Adair, David Streiner, Brianna Kopp, Scott Veldhuizen, Eric Latimer, Paula Goering

The national At Home/Chez Soi project team: Jayne Barker, PhD, (2008-11), Cameron Keller (2011-14), and Catharine Hume (2014-present) MHCC National Project Leads; Paula Goering, RN, PhD, Research Lead, and approximately 40 investigators from across Canada and the US. In addition there were 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 Canada. The views expressed herein solely represent the authors.

/ 28

At Home/Chez Soi: National Research Team

• Paula Goering, CAMH, University of Toronto, Research Lead

• Carol Adair, University of Calgary

• Tim Aubry, University of Ottawa

• Jeffrey Hoch, St. Michael’s Hospital, University of Toronto, University of Western Ontario

• Geoff Nelson, Wilfrid Laurier University

• Myra Piat, Douglas Mental Health University Institute; McGill University

• David Streiner, Baycrest Hospital; University of Toronto

• Sam Tsemberis, Pathways to Housing, Inc

/ 29

At Home/Chez Soi Local Leads

Moncton: Tim Aubry, University of Ottawa; & Jimmy Bourque, Université de Moncton

Toronto: Stephen Hwang, St. Michael’s Hospital, University of Toronto; Vicki Stergiopoulos, St. Michael’s Hospital, University of Toronto; & Pat O’Campo, St. Michael’s Hospital, University of Toronto

Montreal: Eric Latimer, Institut Douglas, McGill University; & Christopher McAll, Université de Montréal

Winnipeg: Jino Distastio, University of Winnipeg; & Jitender Sareen, University of Manitoba

Vancouver: Julian Somers, Simon Fraser University; Michael Krausz, University of British Columbia; & Jim Frankish, University of British Columbia

/ 30

Visit: www.mentalhealthcommission.ca (for detailed information and reports)

Visit: www.nfb.hereathome.ca (for video short stories about the project and our participants)

Visit: www.housingfirsttoolkit.ca (for the Canadian Housing First Toolkit)

Questions? Contact: gnelson@wlu.ca or taubry@uottawa.ca