Cross-Site P.

NATIONAL FINAL REPORT

Cross-Site At Home/Chez Soi Project

www.mentalhealthcommission.ca
NATIONAL AT HOME/CHEZ SOI FINAL REPORT
This report was prepared by a small team led by Paula Goering, which included Scott Veldhuizen, Aimee Watson, Carol Adair, Brianna Kopp, Eric Latimer,
Tim Aubry, Geoff Nelson, Eric MacNaughton, David Streiner, Daniel Rabouin, Angela Ly, and Guido Powell. We also thank Jayne Barker (2008-11), Cameron
Keller (2011-12), and Catharine Hume (2012-present), Mental Health Commission of Canada At Home/Chez Soi National Project Leads, as well as the National
Research Team, the five site research teams, the Site Co-ordinators, the numerous service and housing providers, and people with lived experience who
have contributed to this project and the research. We would, most especially, like to acknowledge the contributions of At Home/Chez Soi participants, whose
willingness to share their lives, experiences, and stories with us were central and essential to the project.
Production of this document is made possible through a financial contribution from Health Canada. The views represented herein solely represent the views
of the Mental Health Commission of Canada.

CITATION INFORMATION
Suggested citation: Paula Goering, Scott Veldhuizen, Aimee Watson, Carol Adair, Brianna Kopp, Eric Latimer, Geoff Nelson, Eric MacNaughton, David Streiner
& Tim Aubry (2014). National At Home/Chez Soi Final Report. Calgary, AB: Mental Health Commission of Canada.
Retrieved from: http://www.mentalhealthcommission.ca

COPYRIGHT
© 2014 Mental Health Commission of Canada
Suite 320, 110 Quarry Park Blvd SE, Calgary, Alberta, T2C 3G3

2
AT HOME/CHEZ SOI FINAL REPORT CROSS-SITE
TABLE OF CONTENTS

Main Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter 1 - Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
The Policy Issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Housing First . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Chapter 2 - Study Background and Implementation of the Housing First Intervention in the Five Cities . . . . . . . . . . . . . 11
At Home/Chez Soi Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
The Research Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
The Intervention - Housing First and Treatment as Usual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Implementing At Home/Chez Soi – Overview of the Five Cities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Lessons from Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Understanding Local Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Assessment of Fidelity to the HF Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Fidelity and Site Program Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 3 - Study Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

The Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Homelessness History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Past–Current: Personal, Health, and Social Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 4 - Housing Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Housing Stability Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Differences in Types of Shelter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Housing Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Participants with Additional or Other Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Landlord Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Chapter 5 - Service Use and Cost Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Health Service Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Justice Service Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Cost Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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TABLE OF CONTENTS

Chapter 6 - Social and Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Quality of Life and Community Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Health and Substance-Related Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
How Life Courses Differed Between Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Factors Related to Positive Life Courses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Factors Related to Negative Life Courses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Factors Related to Mixed or Neutral Life Courses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
The Relationship between Program Fidelity and Key Study Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Chapter 7 - Implications for Practice and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
What's Next? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Appendix A - Overview of Study Design and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Appendix B - Housing-Related Statistics for At Home/Chez Soi Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix C - Fidelity Assessment Methods and Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Appendix D - Key Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Appendix E - Details of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

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MAIN MESSAGES
FROM THE CROSS-SITE AT HOME/CHEZ SOI PROJECT
After successfully engaging and following more than 2,000 participants for two years, the results for
At Home/Chez Soi, the world’s largest trial of Housing First (HF) in five Canadian cities, can now be reported.

Housing First can be effectively implemented in It is Housing First, it is not housing only. Most
1 Canadian cities of different size and different 4 participants were actively engaged in support and
ethnoracial and cultural composition. HF provides treatment services through to the end of follow-up. The
immediate access to permanent housing with general shift away from crisis and institutional services to
community-based supports. The HF program community-based services that was seen at 12 months
participants in this study were provided with an continued for the duration of the study. Many individuals
apartment of their own, a rent supplement, and one of with previously unmet needs were able to access
two types of support services: those with high needs appropriate and needed services during the study.
received Assertive Community Treatment (ACT) and
Having a place to live with supports can lead to other
those with moderate needs received Intensive Case
Management (ICM). HF programs were operated in a
5 positive outcomes above and beyond those provided
by existing services. Quality of life and community
manner that was consistent with the HF model
functioning improved for HF and TAU participants, and
standards, but were tailored to best fit the local contexts
improvements in these broader outcomes were
in the five cities.
significantly greater in HF, in both service types.
Housing First rapidly ends homelessness. Across all Symptom-related outcomes, including substance use
2 cities, HF participants obtained housing and retained problems and mental health symptoms, improved
their housing at a much higher rate than the treatment similarly for both HF and TAU. However, since most
as usual (TAU) group. In the last six months of the study, existing services were not linked to housing, there was
62 per cent of HF participants were housed all of the much lower effectiveness in ending homelessness for
time, 22 per cent some of the time, and 16 per cent none TAU participants.
of the time; whereas 31 per cent of TAU participants were
There are many ways in which Housing First can
housed all of the time, 23 per cent some of the time, and
46 per cent none of the time. Findings were similar for
6 change lives. While the HF groups, on average,
improved more and described fewer negative
ACT and ICM participants. Among participants who were
experiences than the TAU groups, there was great
housed, housing quality was usually better and more
variety in the changes that occurred. Understanding the
consistent in HF residences than TAU residences. We
reasons for differences of this kind will help to tailor
now know more about the small group for whom stable
future approaches.
housing was not achieved by HF, and about some
Getting Housing First right is essential to optimizing
7
additions or adaptations that may work better for them.
outcomes. Housing stability, quality of life, and
Housing First is a sound investment. On average the
3 HF intervention cost $22,257 per person per year for
community functioning outcomes were all more
positive for programs that operated most closely to HF
ACT participants and $14,177 per person per year for ICM
standards. This finding indicates that investing in
participants. Over the two-year period after participants
training and technical support can pay off in improved
entered the study, every $10 invested in HF services
outcomes. Other important implications for policy are
resulted in an average savings of $9.60 for high needs/
discussed in this report. In addition, lessons learned
ACT participants and $3.42 for moderate needs/ICM
have now been incorporated into a toolkit to guide the
participants. Significant cost savings were realized for the
planning and implementation of effective Housing First
10 per cent of participants who had the highest costs at
programs in Canada.
study entry. For this group, the intervention cost was
$19,582 per person per year on average. Over the
two-year period following study entry, every $10 invested
in HF services resulted in an average savings of $21.72.

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EXECUTIVE SUMMARY
FROM THE CROSS-SITE AT HOME/CHEZ SOI PROJECT

Homelessness is a serious public policy concern.

Each year, up to 200,000 people are homeless in
Canada — at an estimated cost of seven billion dollars.

In Canada, our current response relies heavily upon existing approaches in each city. The examination of quality
shelters for emergency housing and emergency and crisis of life, community functioning, recovery, employment, and
services for health care. Typically, individuals who are related outcomes was unprecedented, as was the inclusion
homeless must first participate in treatment and attain a of two types of support services for individuals with high
period of sobriety before they are offered housing. This is needs (Assertive Community Treatment, or ACT) and
a costly and ineffective way of responding to the problem. moderate needs (Intensive Case Management, or ICM).
Alternatively, Housing First (HF) is an evidence-based The study also used a standardized model of HF, conducted
intervention model, originating in New York City (Pathways assessments of program fidelity to document the quality
to Housing), that involves the immediate provision of program implementation, introduced quality assurance
of permanent housing and wrap-around supports to processes, and provided extensive training, technical
individuals who are homeless and living with serious mental assistance, and support.
illness, rather than traditional “treatment then housing” A randomized trial design was used in the project because it
approaches. HF has been shown to improve residential could evaluate the effects of HF in groups that were virtually
stability and other outcomes. Given the difference in identical except for the intervention itself, thus giving the
social policy and health care delivery between the U.S. strongest evidence for policy. The study also included a
and Canada, it is vital that evidence about homelessness qualitative research component to complement and better
interventions be grounded in the Canadian context. inform the quantitative results (mixed methods design). Data
In 2008, the federal government invested $110 million collection began in October 2009 and ended in June 2013.
for a five-year research demonstration project aimed 2,148 individuals were enrolled for two years of follow-up and
at generating knowledge about effective approaches of those, 1,158 received the HF intervention. Follow-up rates
for people experiencing serious mental illness and at 24 months were between 77 and 89 per cent, which are
homelessness in Canada. In response, the Mental Health excellent for a vulnerable and highly transient population.
Commission of Canada (MHCC) and groups of stakeholders This document reports on the main findings of the study
in five cities (Vancouver, Winnipeg, Toronto, Montréal, and for the full two years of follow-up. It builds on the At Home/
Moncton) implemented a pragmatic, randomized controlled Chez Soi Interim Report (September 2012), which presented
field trial of HF. The project, called At Home/Chez Soi, was the preliminary one-year results. Reports containing greater
designed to help identify what works, at what cost, for detail about local findings and implications for local practice
whom, and in which environments. It compared HF with and policy are also available for each of the five cities.

6
Program Implementation last six months of the study, 62 per cent 229 TAU residences. The HF residences
of HF participants were housed all of the (unit and building combined) were found
The study demonstrated that HF can be
time, 22 per cent some of the time, and across sites to be of significantly greater
implemented successfully in different
16 per cent none of the time; whereas quality and of much more consistent
Canadian contexts, using both ACT and
31 per cent of treatment as usual (TAU) quality than those that TAU participants
ICM models for the service component.
participants were housed all of the time, were able to get on their own or using
It also demonstrated that HF can be
23 per cent some of the time, and 46 per other housing programs and services.
effectively adapted according to local
cent none of the time. These significant There were moderate site differences in
needs, including rural and smaller
gains in obtaining and retaining housing these findings.
city settings such as Moncton and
held for participants in both the ACT and
communities with diverse mixes of people
(e.g., Aboriginal or immigrant populations)
ICM versions of HF. Over the course of the Costs and Service Use
study, TAU participants spent significantly One of the advantages of stable housing
like Winnipeg or Toronto.
more time in temporary housing, shelters, for a group who have high levels of
and on the street than HF participants. chronic mental and physical illness is
Study Participants The most dramatic effects were found the possibility of shifting their care from
Most At Home/Chez Soi study participants in the first year, where the HF program institutions to the community. Community
were recruited from shelters or the streets. “jumpstarts” getting housed. Many HF services including visits from the HF
The typical participant was a male in his participants spoke of the importance of service providers and phone contacts
early 40s, but there was a wide diversity “having their own place” and described increased as intended and, particularly for
of demographic characteristics. Women their housing as a safe and secure “base” the high needs group, inpatient and crisis-
(32 per cent), Aboriginal people (22 per from which to move forward with their type service use fell. Most of the service
cent), and other ethnic groups (25 per lives. One noted, “The security is a really use changes reflect appropriate shifts from
cent) were well-represented. The typical big thing. I can just let go and I have no crisis services to community services, but
total time participants experienced problem just lying down for 12 hours and for some participants, involvement in the
homelessness in their lifetimes was nearly I don’t have to move or be on guard.” program likely resulted in the identification
five years. Participants were found to have (Vancouver participant) of unmet needs for more acute or
had multiple challenges in their lives that rehabilitative levels of care in the short
contributed to their disadvantaged status.
For example, 56 per cent did not complete
Clients with Additional or term. These shifts in service use create
cost savings and cost offsets that can be
high school, and almost everyone was Other Needs taken into account when making decisions
living in extreme poverty at study entry. HF worked well for clients with diverse
about where to target future programs
All had one or more serious mental illness, ethnocultural backgrounds and and how to avoid future cost pressures.
in keeping with the eligibility criteria of circumstances. We now know more about
the small group (about 13 per cent) for For the 10 per cent of participants with the
the study, and more than 90 per cent
whom HF as currently delivered did not highest service use costs at the start of the
had at least one chronic physical health
result in stable housing in the first year. study, HF cost $19,582 per person per year
problem. Using qualitative interviews with
This group tended to have longer histories on average. Receipt of HF services resulted
a representative sample and quantitative
of homelessness, lower educational in average reductions of $42,536 in the
measures, we have documented the early
levels, more connection to street-based cost of services compared to usual care
origins of homelessness in the life histories
social networks, more serious mental participants. Thus every $10 invested in
of participants, which very often included
HF services resulted in an average savings
early childhood trauma and leaving home health conditions, and some indication of
of $21.72. The main cost offsets were
to escape abuse. greater cognitive impairment. Alternative
psychiatric hospital stays, general hospital
approaches to addressing the unique
stays (medical units), home and office
Housing Outcomes needs of these clients were tried in
visits with community-based providers,
some cities. Recommendations on these
HF was found to have a large and jail/prison incarcerations, police contacts,
approaches will be available in the Housing
significant impact on housing stability. emergency room visits, and stays in
First implementation toolkit.
A substantial majority of participants crisis housing settings and in single room
maintained stable housing during the accommodations with support services.
study period, indicating that the attention Housing quality For this group, two costs increased:
paid to client choice and service team Our field research teams systematically hospitalization in psychiatric units in
support quickly resulted in securing measured housing quality using standard general hospitals and stays in psychiatric
desirable and affordable housing. In the ratings in a random sample of 205 HF and rehabilitation residential programs.

7
Quality of Life, Functioning, Mental Health, and Substance Use Outcomes
Living in shelters and on the streets gains in participant-reported quality TAU reported a positive life course, 36 per
requires that enormous energy be put into of life and observer-rated community cent reported a mixed life course, and 36
basic survival. The circumstances are not functioning were significantly greater per cent reported a negative life course.
conducive to participating in treatment in HF (for both ACT and ICM) than in The study generated and consolidated
and managing health issues. On average, TAU. These differences were relatively rich information about different sub-
participants had been homeless in their modest, but still represent meaningful populations, diverse responses, and how
lifetime for just less than five years when improvement in outcomes for HF to successfully adapt the approach.
they enrolled in the study, and many had compared to existing services, and indicate
Housing stability, quality of life, and
a history of poverty and disadvantage that HF can impact broader outcomes.
community functioning outcomes were all
reaching back to early childhood. For One Toronto participant described their
more positive for programs that operated
some, the road to recovery after housing experience as: “I am really proud of myself,
most closely to HF standards, including
can be rapid, but for most it is more with a lot of help I was…able to…not really
the provision of rent subsidies. HF model
gradual and setbacks are to be expected. get back to where I used to be, but in
standards were measured on 38 items in
In general, the study documented clear a better place.” (Toronto participant)
five domains for 12 programs at two time
and immediate improvements, followed While the HF groups on average improved points in the study (early implementation
by more modest continuing ones for more on the major outcomes, the individual and one year later). Overall there was
the remainder of the study period. Some responses in both HF (ICM and ACT) and strong fidelity to HF standards (with all
outcomes, including mental health and TAU over time were enormously diverse. items rated above 3 on a 4-point scale),
substance use problems, improved by a Across all sites in the qualitative interviews, and this improved over time (71 per cent
similar amount in both HF and TAU. These 61 per cent of the HF participants described in round one and 78 per cent in round
improvements may be due to services a positive life course since the study began, two). This indicates that supporting
that can be accessed by both groups, or 31 per cent reported a mixed life course, all components of the HF model and
may represent natural improvement after and eight per cent reported a negative investing in training and technical support
a period of acute homelessness. However, life course. In contrast, only 28 per cent of can pay off in improved outcomes.

“I am really proud of myself, with a lot of help I was…

able to…not really get back to where I used to be,
but in a better place.” (Toronto participant)

8
CHAPTER 1
INTRODUCTION

After successfully
engaging and
following more than
2,000 participants
in five Canadian
cities for two years,
the results for the
At Home/Chez Soi
project, the world’s
largest trial of
Housing First
(HF), can now
be reported.

This Final Report documents the main This report builds on the Interim Report (September 2012), which presented the preliminary
findings of the study, funded by Health results after one year of follow-up. Final Reports are also available for each of the five cities
Canada and implemented by the Mental that contain greater detail about local findings and implications for local practice and policy.
Health Commission of Canada (MHCC),
for the full two years of follow-up. Its Across Canada, up to 200,000 people
key questions include the following:
are homeless annually.
• Can HF be implemented in Canada,
and can it respond to local and The Policy Issue
regional contexts and the unique
Homelessness is a serious public policy concern in Canada and elsewhere. Across
needs of different sub-populations?
Canada, up to 200,000 people are homeless annually1. Homelessness has a
• What are the characteristics of significant impact on individuals, families, and communities in Canada. It takes a toll
individuals who participated in on people’s physical health, mental health, and quality of life. It can significantly reduce
the At Home/Chez Soi study? a person's life expectancy2 and can exacerbate existing mental health problems. It
• How has HF affected participants’ also negatively affects a person’s chances to engage in employment and positive
ability to get housing and stay stably family and social relations, and impacts the ability of communities to benefit from the
housed, and what are participants’ full participation of all citizens. In contrast, access to safe, affordable, secure housing
experiences with housing? has been shown to improve people’s health and wellbeing and reduce stress3.

• What is the impact of HF on health, Homelessness is often the result of a mix of structural factors, and service and system
social, and justice/legal system failures, as well as social and individual factors (e.g., a lack of affordable housing and
service use and costs? Does suitable support services, mental health and addictions issues, poverty, stigma and
continued investment in HF, as discrimination, violence and trauma).4 In addition, certain populations experiencing
one innovative solution to chronic homelessness (e.g., families, women, seniors, youth, new immigrants, Aboriginal people5)
homelessness, make sense from have unique needs requiring tailored solutions. Those with mental health issues, who
social and economic perspectives? are among all of these populations, are particularly vulnerable to housing instability
and homelessness, and can become trapped in a cycle of poverty and poor health.
• How has HF affected participants’ It has been projected that up to 67 per cent of people who were homeless reported
quality of life, community functioning, having a mental health issue in their lifetime,6 which can increase the complexity and
and mental and physical health? duration of their homelessness, resulting in many becoming chronically homeless.7

9
 HF =
Housing First
Permanent
Housing +
Housing First supports people who are homeless and living with mental illness by combining the immediate provision of
permanent housing with wrap-around supports.

Housing First
While there are examples of programs across Canada that are helping to end
homelessness and improve access to affordable housing, generally, our current

Housing
response to homelessness relies heavily upon shelters for emergency housing
and acute care services, such as emergency room visits, for health care. This is
a costly and ineffective way of responding to the issue. In Canada, it is estimated

First that homelessness costs seven billion dollars each year in health care, justice
and social service use.8 Housing First (HF) is one of the effective approaches

principles:
that is being implemented in Canada. It is an evidence-based intervention,
originating in New York City (Pathways to Housing), that involves the immediate
provision of permanent housing and wrap-around supports to individuals who
are experiencing homelessness and living with serious mental illness. The HF
approach is grounded in principles of immediate access to housing with no
Immediate access to
1 housing with no housing
housing readiness conditions, consumer choice and self-determination, recovery
orientation (including harm reduction), individualized and person-driven supports,
readiness conditions and social and community integration.9
Housing First is becoming well-known internationally and it has been
Consumer choice and
2 self-determination
implemented in some Canadian cities with positive outcomes; for example,
Toronto’s Streets to Homes program is a well-established Canadian program
based on the HF approach. However, most of the evidence to date on HF has
Recovery orientation been based on programs in large American cities. Given the differences in health
3 care and social policies between the U.S. and Canada, it is vital that evidence
about the HF approach be grounded in the Canadian context. As a result, in
Individualized and 2008, the federal government invested $110 million for At Home/Chez Soi, a
4 person-driven supports five-year research demonstration project to help understand the potential of
HF in Canadian communities.
Social and community
5 integration
Drawing from the Canadian-based evidence produced by At Home/Chez Soi
to date, the federal government announced, in its 2013 budget, an investment
of $600 million over five years (beginning in 2014) through the Homelessness
Partnering Strategy. This investment will support communities to reduce
homelessness and facilitate the implementation of the Housing First approach
across Canada.

“We have the mental health commission showing us that intensive

work with these people helps keep them housed and on track,” the
mayor said. “We have a successful model here, and we’re going to
keep pressing the government on more investment in this approach.”
Source: Vancouver Sun Gregor Robertson makes mental health Vancouver’s new priority. Read more: http://bit.ly/1jAovg5

10
CHAPTER 2
STUDY BACKGROUND AND IMPLEMENTATION OF
THE HOUSING FIRST INTERVENTION IN THE FIVE CITIES

Cross-Site P.7

VANCOUVER WINNIPEG TORONTO MONTRÉAL MONCTON

In this chapter, we describe how the study was implemented, including adaptation of the model to local contexts and the processes
used to ensure service quality. The chapter addresses the question: Can HF be implemented in Canada, and can it respond to local and
regional contexts and the unique needs of different sub-populations?

At Home/Chez Soi Background

To learn more about how to address homelessness for Canadians living with serious mental health issues and the potential of Housing
First (HF) in particular, the federal government invested $110 million in 2008 for a five-year research demonstration project. In response,
the Mental Health Commission of Canada (MHCC) and stakeholders in five cities (Vancouver, Winnipeg, Toronto, Montréal and Moncton)
implemented a pragmatic randomized controlled field trial of HF (see Appendix A for study design details). The project, called At Home/
Chez Soi, was designed to help identify what works, at what cost, for whom, and in which environments. It compared HF with existing
services in each city. The inclusion of two levels of intensity of support services for individuals with high needs (Assertive Community
Treatment or ACT) and moderate needs (Intensive Case Management or ICM) was unprecedented. The study also used a standardized
model of HF; extensive training, technical assistance, and support was provided; assessments of program fidelity to document the degree
of program implementation were conducted; and quality assurance processes were instituted. In addition to the overall study questions,
research teams in each of the five cities investigated additional questions of local interest and importance.

The Research Process

In order to provide the strongest evidence for policy decision- In addition, information was collected from the programs and
making, At Home/Chez Soi used a randomized controlled trial from national and provincial administrative data sources for health
design. This is an optimal research design for measuring the and justice service use. Results in this report are mostly based on
impacts of an intervention, with all other things that could affect housing stability, service use and costs, community functioning,
outcomes being equal. In the study we collected quantitative data and quality of life, over the two years of the study as reported by
(in the form of numbers and scales) and also extensive qualitative participants and observed by the research team. More detailed
data (in the form of text and stories) to complement and inform the and extensive findings are being reported in scientific publications,
quantitative results. Interviews were conducted with participants and further findings, especially those from administrative
at entry to the study and every three months for up to two years. data sources, will be reported in subsequent publications.

11
The Intervention -
Housing First and Treatment as Usual services were provided according to two levels of need
More than 2,000 eligible participants were first grouped into high by ACT (high need) and ICM teams (moderate need).
needs and moderate needs categories, based on mental health
and service use history, and then randomized into the applicable • The ACT programs were provided by multi-disciplinary teams
ACT or ICM HF intervention group or the associated treatment that included a psychiatrist, nurse, and peer specialist among
as usual group (TAU). In addition, each site was offered the others. The ACT teams had a staff to participant ratio of
opportunity to develop a locally adapted HF intervention (often 1:10. The ACT teams met daily, and staff was available seven
called the “Third Arm Intervention”), which resulted in some unique days per week with crisis coverage around the clock.10
team and program structures in each city. • The ICM programs were provided by teams of case managers
Participants in the intervention group received housing and who worked with individuals and brokered health and other
services based on the HF model, which provides immediate related services as needed. The staff to participant ratio was
access to permanent housing. Housing was provided through initially 1:20 but was later changed to 1:16 because the needs of
rent subsidies, with participants paying up to 30 per cent of their the moderate needs group were greater than expected. ICM
income towards their rent. Participants had a choice around teams held case conferences at least monthly and services
the housing and supports they needed, with a requirement were provided seven days a week, 12 hours per day11.
that participants meet with a member of their support team at By comparison, the treatment as usual group had access to the
least once a week. The majority of the housing was provided existing housing and support services in their communities.
through private market rental units, although, where available, In some cities, this included a range of options, with other
participants were also offered a choice of supportive and/or supportive housing programs and treatment resources
social housing. Individualized, recovery-oriented supportive available, while in other cities there were fewer options.

Implementing At Home/Chez Soi – Overview of the Five Cities

Lessons from Implementation
In addition to researching the outcomes achieved through HF, we were also interested in documenting and understanding how HF was
implemented across the project sites to learn about how it could be adapted within a Canadian context to meet unique local needs. A
series of qualitative reports have been released which explore the key lessons from the conception, planning and implementation of the
project.12 The following key elements were identified as being important to implementation of HF locally and nationally:
• having a strong mix of partners and stakeholders engaged in the project;
• understanding the value of having champions and leadership come from unexpected places;
• navigating the complexity of cross-ministerial and cross-departmental government collaboration;
• ensuring there is clarity of purpose and deliverables along with a clear definition of HF and fidelity standards;
• valuing the importance of training and technical assistance.

Understanding Local Variations

At Home/Chez Soi demonstrated that HF can be implemented in Canada and successfully adapted to local contexts. Each of the five At
Home/Chez Soi sites operated within a unique local context that influenced both the experience of the TAU group as well as the way the
HF intervention was implemented. The following section describes some of these variations in the local contexts.
• Population Characteristics – Moncton is the smallest of the five sites, and included a rural pilot study to improve understanding
of rural homelessness. Montréal is a larger city that has a diverse population and has a strong history of supporting social housing
as its preferred model. Toronto is the largest of the five sites and has the highest population of people who identify as being from
an ethnoracial community.13 Vancouver is the next largest site and it is characterized by its concentration of people experiencing
homelessness in the Downtown East Side community, where serious drug use is highly prevalent. Winnipeg is a moderate-sized city
that has a large Aboriginal population, a group that is over-represented within Canada's homeless population.
• Housing Contexts – Each site is characterized by varying levels of access to affordable housing, but all sites have many people living
in core housing need (defined as housing that is not adequate, suitable or affordable 14 ). As well, most sites have low vacancy rates and
relatively high rental costs that are eroding the affordability of available rental housing (see Appendix B for related details). Most sites
also have long waiting lists for access to social housing or other housing options.
• Service Contexts – Sites also varied in the levels and types of services and supports available. Moncton had the lowest number of
community mental health services available and no ACT teams. In Montréal, Winnipeg, and Vancouver, access to ACT or ICM services
was limited; however, there were other shelter, housing, and mental health services available. Of all the sites, Toronto had the greatest
availability of mental health services, but even those existing services are considered insufficient to meet the range of service needs in
the city. 15
Assessment of Fidelity to the HF Model
The At Home/Chez Soi service teams were offered training and technical assistance to ensure that services were “true” to the
program model (also called fidelity) and that core standards were common across all programs. Local adaptations to the program
model were also encouraged to meet local needs. All sites received two fidelity visits (at the end of the first year and another near
the end of the second year) that reviewed both adherence to the HF model and local adaptations (see Appendix C for details).
Although there is some debate on this,16 adaptations to local context are possible and desirable and can occur without compromising
the essential principles or functions of the intervention.17 This fits with our experience in the At Home/Chez Soi study.
The Pathways HF Fidelity Scale was used to assess program fidelity.18 Two versions of the Pathways HF Fidelity Scale were developed — one
for ACT and one for ICM (provided in Appendix C). Each scale measured 38 items across five domains — housing choice and structure,
separation of housing and services, service philosophy, service array, and program structure — all of which are key elements of HF.

Fidelity and Site Program Variations

Overall, At Home/Chez Soi achieved a high level of fidelity to the HF model. There was good consistency of program structure and
commitment to core principles. Teams were successful in balancing their local context and needs and aligning those with the HF model.
Program variations, i.e., third-arm interventions in each site, are outlined below. Individual site reports are also available on the MHCC's
website and provide greater detail about local findings and policy implications.

Vancouver Toronto Moncton

One hundred The site-specific Because of smaller
participants were intervention targeted numbers, the
provided HF through the needs of people Moncton site’s HF
a congregate site from racialized program used an ACT
model at the Bosman groups who were team only. Moncton
Hotel, which is operated by the Portland experiencing homelessness and mental also studied the impact of a rural ACT
Hotel Society. Participants had their own illness, and was informed by Anti-Racism/ team, which provided housing, services
room and washroom, and access to Anti-Oppression (AR/AO) principles. The and support for 24 people living in rural
individualized on-site health, mental health, organization Across Boundaries delivered southeastern New Brunswick. Prior to
and addictions services, including clinical the program that assisted immigrants and joining the program, participants lived
care (nursing care, medication support), people from racialized groups with housing either in Special Care Homes, with their
social support (groups, programming), and and clinical supports. In addition, the HF families, in rooming houses, or were
case management. Staff was available 24 fidelity scale was supplemented with homeless. The rural arm of the ACT team
hours a day, seven days a week and two measures of AR/AO principles. operated with a participant to staff ratio of
meals were provided daily. Findings for approximately 8:1, a common standard for
those who received the congregate living rural ACT services. The rural study findings
Montréal
“third arm” in Vancouver (at the Bosman) employed a different study design and
Some interested
are excluded from this report because the those findings are reported separately in
participants in
program model differed in important ways the Moncton Final Report.
Montréal were
from the main intervention. Findings for
offered access to One goal of the At Home/Chez Soi
the congregate intervention are outlined in
the Individualized project was to understand if the HF
the Vancouver Final Report.
Placement and Support (IPS) model to approach could be implemented in
help them find and maintain competitive Canadian communities and if adaptations
Winnipeg employment. Participants were provided to local contexts were possible.
The Aboriginal Health with personalized employment supports Implementation and fidelity research
and Wellness Centre (e.g., assistance writing résumés, in the study demonstrated clearly that
offered the Ni-Apin introductions to potential employers, both are possible. The context and
Program as the site- and preparing for job interviews). implementation findings noted here
specific intervention. IPS staff also worked directly with provide a foundation for understanding
It was an ICM-based model and included a employers to find appropriate job participant outcomes, which are
day program. Ni-Apin delivered HF based opportunities and to educate them on discussed in the following chapters.
on the Medicine Wheel philosophy and how to support their new employees.
Indigenous Framework. Elders were part of
the service team and were accessible for
individual meetings and for sharing and
teachings circles.

13
CHAPTER 3
STUDY PARTICIPANTS

This chapter provides detail for the and follow-up details). Sixty-two per cent AVERAGE LIFETIME

4.8
question: What are the characteristics of participants met the definition for HOMELESSNESS
of individuals who participated in moderate needs and 38 per cent for high
the At Home/Chez Soi study? needs, and, as such, were eligible for ICM
or ACT respectively. All findings in this
The2,148
Sample
Participants report (unless otherwise noted) are based
on these 2,148 participants. In addition,
qualitative data were collected for a

YEARS
subsample of participants (219 at baseline
and 197 at 18 months), that represented the
larger sample.
990 In the next sections, the sample is
described for demographic, homelessness
Treatment female, and one per cent identified as
as Usual 1,158 history, health, and social circumstances.
Tables that include more detailed
“other.” Twenty-two per cent of participants
identified as being Aboriginal and 25 per
Housing information are provided in Appendix E. cent identified as being from another
First
ethnic group. Participants in the high
Demographic needs (HN) group tended to be younger,
Characteristics with 39 per cent of participants aged 34
or younger compared to 29 per cent of
The “typical” participant was a male in
All 2,148 participants were divided into participants aged 34 or younger in the
his early 40s, but there was enormous
one of two categories. moderate needs (MN) group. Almost all
diversity in demographic characteristics
participants (96 per cent) were single,
across the sample. 67 per cent of
2,148 individuals were enrolled in the study separated, divorced or widowed. Many
participants were male, 32 per cent were
across all five sites and, of those, 1,158
received the HF intervention and 990
were randomized to TAU. Follow-up rates GENDER
at 24 months were between 77 and 89 per
cent (up to 91 per cent in one site), which Male Female
are excellent for a vulnerable and often
Participant Characteristics

transient population (see Appendix D ETHNICITY

for a definition of the eligibility criteria,
Aboriginal Other

RELATIONSHIP STATUS
62% 38% Single, Separated, Divorced or Widowed

DEPENDANTS
Moderate High One or more
Need Need children
ICM ACT
0 20 40 60 80 100
Levels were determined by the variety
of needs of the participants. Percentage %

14
 Homelessness History
EDUCATION LEVEL Most study participants were recruited
from shelters or the streets, with 82
Did not complete high school per cent absolutely homeless and 18
per cent in precarious living situations
(refer to Appendix D for definitions of
"absolute" and "precarious" homelessness).
EMPLOYMENT STATUS
Education and Employment

Many reported histories of ongoing

homelessness. The average total time
Unemployed at study entry homeless over participants’ lifetimes was
slightly less than five years. The typical
age of first homelessness was 31, but more
PREVIOUS EMPLOYMENT STATUS than 40 per cent reported having their first
episode of homelessness before the age
of 25. In general, those who were in the
Employed in the past
HN group were homeless earlier and at a
younger age, had a longer average period
of homelessness, and had a greater total
VETERANS lifetime homelessness than those who
were in the MN group.

Past–Current: Personal,
Health, and Social
Circumstances
0 20 40 60 80 100
All participants had one or more serious
Percentage % mental illness, in keeping with the eligibility
criteria of the study. At entry, participants
reported symptoms consistent with the
were parents, with 31 per cent reporting high school (59 per cent). The average
presence of the following mental illnesses:
having one or more children, though income reported for the month prior to
34 per cent had a psychotic disorder, 71
few of these children were living with the study entry was less than $685 per month,
per cent had a non-psychotic disorder, and
participant at the time of study entry. and 15 per cent of participants reported
67 per cent reported substance-related
The findings underscored the fact that an income of less than $300 per month.
problems. A substantial proportion (46 per
participants had and were facing multiple While 93 per cent were unemployed at
cent) had more than one non-substance-
challenges in their lives that contributed to the time of study entry, more than 66 per
related mental illness and a majority (73
their marginalized status. For example, 55 cent had worked steadily in the past. A
per cent) had more than one mental
per cent did not complete high school, and small but important proportion (four per
illness including a substance-related illness
nearly all were living in extreme poverty. cent) of participants were veterans, having
(any of alcohol or drug dependence or
The HN group had a greater percentage reported wartime service for Canada or an
use). Also in line with the definition of
of participants who did not complete allied country.
high versus moderate needs, psychotic

100
Percentage % of Participants

80

Non-
60 Substance
Psychotic
-Related
Problems

$685
40
Psychotic
20
AVERAGE INCOME
PER MONTH 0
Serious Mental Illnesses Reported at Entry
15
On average, participants reported 4-5 of these adverse childhood experiences, which had a court appearance, and 11 per cent
are risk factors associated with mental illnesses and homelessness. reported participation in a justice service
program in the prior six months. Many
participants also experienced victimization
100
in the six months prior to study entry:
that Experienced Risk Factors

32 per cent reported being robbed or

Percentage % of Participants

80 threatened to be robbed, 43 per cent

reported being threatened with physical
assault, and 37 per cent reported being
60 physically assaulted.

Exposed at Home to
Substance Misuse
While all participants had some degree
40 of disability, nine per cent had high levels,
45 per cent had moderate disability, and
Emotional

Household
Domestic

in Prison
Violence

Member
46 per cent had lower levels of disability
Physical

20

Neglect
Sexual

according to our standard observer-

rated community functioning scale (the
0 Multnomah Community Ability Scale —
Childhood Abuse Living Circumstances see Appendix A for more information).
Participants in the HN group had lower
disorders were more common in HN or more traumatic head injuries involving average scores on this scale (54 versus 65),
than MN (52 per cent versus 22 per cent). unconsciousness. More than 90 per which was expected given that the cut-off
Moreover, those in HN also reported more cent of participants reported at least one score for determining need level was 62.
substance-related illnesses (73 per cent chronic physical health problem. Common Participants also often lacked basic social
versus 62 per cent). serious physical health conditions included support — around half reported having no
asthma (24 per cent), hepatitis C (20 per one to confide in. General distress levels
Risk factors associated with mental illness
cent), chronic bronchitis/emphysema (18 were also high, with 36 per cent reporting
and homelessness are reflected in the
per cent), epilepsy/seizures (10 per cent), symptoms consistent with moderate to
life histories, recent experiences, and
diabetes (nine per cent), and heart disease high suicide risk. (Note that there were
current circumstances of participants.
(seven per cent). Thirty-seven per cent standard referral processes that were
For example, about 62 per cent, 55 per
of participants had two or more annual followed in the study if a participant was
cent, and 38 per cent reported being
hospital admissions for a mental illness in deemed at risk of suicide.)
emotionally, physically or sexually abused
in childhood, respectively. Thirty-eight one or more of the five years before study As intended, the At Home/Chez Soi
per cent reported “often or very often” enrolment. These figures were higher in study enrolled a group of the most
not having enough to eat, having to wear the HN group compared to the MN group vulnerable Canadians — all with serious
dirty clothes, and not being protected. (54 per cent and 24 per cent, respectively). mental health and/or substance-related
Substantial proportions of participants Over one-third (36 per cent) reported issues and relatively long-standing
also reported experiencing domestic involvement with the criminal justice homelessness histories. Substantial
violence in the household (36 per cent), system in the six months prior to the study, proportions of the participants
living with someone who had substance having been arrested, incarcerated or had suffered early life trauma and
use problems (57 per cent) or having a served probation one or more times. The victimization, had hidden cognitive
household member in jail or prison (31 per HN group reported more involvement with and learning disabilities, and, though
cent). On average, participants reported the justice system than the MN group (43 a minority, a large group had recent
between four and five of these adverse per cent versus 30 per cent). With respect involvement with the justice system. Even
childhood experiences. to the type of legal system involvement, so, many have worked steadily in the past,
24 per cent of participants reported being formed families, or served their country in
Nearly 40 per cent of participants reported
detained or moved along by police, 22 per the military.
having learning problems in school. This
percentage was higher in those in the HN cent reported being held by police for less In the next chapter, we will report on the
group (45 per cent versus 39 per cent in than 24 hours, 27 per cent reported being impact that HF had on our participants
MN). Sixty-six per cent had a history of one arrested, 30 per cent reported having with respect to housing.

16
CHAPTER 4
HOUSING OUTCOMES

The primary objective of HF is to assist a person in finding and staying in permanent housing, and as such, ending chronic homelessness
for that person. In this chapter, we report on and discuss the housing outcomes for At Home/Chez Soi participants, and thereby address
the primary research question: How has HF affected participants’ ability to get housing and stay stably housed, and what are
participants’ experiences with housing?
Over the course of the At Home/Chez Soi study, more than 200 service providers were involved, over 260 landlords and property
management companies recruited, and over 1,200 housing units located. This intensive effort had enormous direct impact on the housing
circumstances of participants. 1,158 individuals randomly allocated to the HF group received housing and comprehensive supports. The
990 participants who were randomized to TAU had access to the range of treatment and housing services available in their communities.
At the time of randomization, those who were randomized to TAU were routinely and actively offered information by study research teams
about existing services. The housing (and other) differences reported herein do not represent outcomes of a new service versus no service;
instead, they represent the value-added benefit of the HF approach against an array of existing services that participants could access or
might be offered.

Housing Stability Outcomes 100 TAU HF

In terms of housing stability, HF was found to be unequivocally
more effective than existing programs accessed by TAU
80
participants for finding housing and staying housed. We examined
Percentage %

stable housing (two years after enrolment) in two ways. First,

we looked at the last six months of the study, and measured the 60
proportions of people who spent every night in stable housing,
who spent at least some of this time in stable housing (See 40
Appendix D), and who were never housed over this period.
The results are shown in Figure 1. 20
As shown, across all cities and both HN and MN groups, in the
last six months of the study, 62 per cent of HF participants were 0
housed all of the time, 22 per cent some of the time, and 16 per None Part-time Full-time
cent none of the time; whereas 31 per cent of TAU participants
were housed all of the time, 23 per cent some of the time, and 46 Figure 1. Percentages of participants housed for various periods of
per cent none of the time. Findings were similar for HN and MN time: last six months of the study
participants. For the HN group, 60 per cent of participants were
housed all of the time compared to 29 per cent of TAU; for the MN
group, 64 per cent of HF participants were housed all of the time highly significant; that is, they are large differences between
compared to 32 per cent of the TAU group. groups with virtually no likelihood of being due to chance.
Specifically, since the study used a randomized design and all
The second way we examined housing outcomes was the
other characteristics that could result in stable housing were
average percentage of days spent in stable housing for
equivalent between groups except the intervention, the finding
individuals in each group for each three-month period of follow-
can be reasonably and confidently attributed to the intervention.
up. As shown in Figure 2, across all sites and in both HN and
MN groups the differences were marked. Over the two years Patterns were very similar in both treatment groups. In ACT,
of the study, participants in HF spent an average of 73 per cent the average time stably housed was 72 per cent in HF and
of their time in stable housing compared with 32 per cent in 33 per cent in TAU. In ICM, it was 72 per cent in HF and 30
TAU. In scientific terms, these differences are considered to be per cent in TAU. Housing outcomes were also very similar for

17
 80 ACT ANALYSIS HF TAU in housing over the course of the study was similar to the full
sample, and the group spoke to the impact housing has had
in their lives. Many in the HF group spoke of the importance of
70 “having their own place” and described their housing as a safe
and secure “base” from which to move forward with their lives.
One noted, “The security is a really big thing. I can just let go and
Percentage %

50 I have no problem just lying down for 12 hours and I don’t have
to move or be on guard.” (Vancouver participant). According
to participants, a prominent reason for their housing stability
30 was that housing catalyzed hope that they could “get back on
track,” which provided them with the motivation to “do what it
takes” to keep their housing and get their lives back. In other
10
words, housing itself was intrinsically motivating to participants,
0 since it inspired people to behave in a way that would maintain
Base 3 6 9 12 15 18 21 24 their tenancies, and allow them to reclaim their lives. Housed
Days participants from the HF group reported more choice over
Figure 2. Per cent of follow-up days spent in stable housing by where they lived, including the choice to live in a place where
study group over 24 months over three-month periods. they felt safe, and in some cases away from previous problematic
social circles. Finally, housed participants in the HF group often
expressed a feeling of stability and permanence. In contrast, TAU
all sites, but there were some minor differences that can be
participants who were able to obtain housing often reported
explained in terms of the differences in site samples, housing
less choice over where they lived, and a lesser sense of safety.
stock, rental vacancy rates, core housing need (i.e., per cent
of housing falling below acceptable standards of adequacy,
affordability or suitability) and the degree to which programs Differences in Types of Shelter
were “true” to the model — that is, the quality/fidelity of While stable housing was the most important outcome we
program delivery. These details are presented in site reports. examined, we also looked at patterns in various types of shelter
The per cent of days housed graph (Figure 2) also illustrates the used over time and by study group. Over the course of the
impact of HF on the dynamic of becoming housed over time. study, people in TAU spent about 33 per cent of their time in
The focus on immediate housing with no preconditions seemed temporary housing, 16 per cent in emergency shelters, 11 per cent
to “jumpstart” housing stability. The most dramatic changes in in institutions, and eight per cent living on the street. Participants
the HF group occurred in the first six months. While more days in HF spent less time in each of these settings: 12 per cent in
spent stably housed are seen over time in the TAU group, these temporary housing, six per cent in shelters, nine per cent in
rates did not come close to the HF housing stability rates. institutions, and three per cent on the street.

We also examined housing outcomes using qualitative interviews Use of various types of shelter is where the picture for HN and MN
with a subsample of participants from both the HN and MN groups participants begins to vary in ways that are consistent with their
and from all sites. These participants were broadly similar to the pre-study service use and levels of need. For example, we see both
wider sample, but had somewhat higher levels of substance use more use and more of a contrast between intervention and TAU
problems and higher incomes at baseline. Their improvement groups in time spent in institutions (including hospitals, prisons,

FIGURE 3-. Days in institutions by study group and type of program

Figure 3. Days in institutions by study group and type of program.

ACT ANALYSIS HF TAU 20 ICM ANALYSIS HF TAU

20

15 15
Days
Days

10 10

5 5
Base 3 6 9 12 15 18 21 24 Base 3 6 9 12 15 18 21 24
Months Months
18
 jails, and addiction treatment facilities) within the HN participants
served by ACT and somewhat greater prior use and contrast for
...those with substance use
MN participants served by ICM with shelter days. These service
use differences by program have implications for the economic
problems at baseline maintained
analyses, as we will see later in Chapter 6. stable housing to a similar
Housing Quality degree as the overall sample.
The physical quality of participants’ housing was measured
systematically using a rating scale developed and standardized
for the study. Ratings were made by two trained members of network/better quality of life while homeless, and to present with
field research teams in a random sample of 205 HF and 229 TAU more serious mental health conditions.
residences that were of a type that could be occupied on a long-
In particular, participants who did not achieve housing stability
term basis. The housing quality scores for HF residences (unit
in the first year reported having been homeless for 8.75 years
and building combined) were found to be of greater quality and
over their lifetime compared to 5.70 years for those participants
much more consistent quality for those housed for at least two
achieving housing stability. Almost two-thirds (66 per cent) of
months on average across sites (which held for four of five sites).
participants in the non-stable housing group had not completed
Additional detail is provided in site reports. Good housing quality
high school compared to 55 per cent of participants who achieved
(that is, residing in a good neighbourhood, where there was a good
stable housing in the first year.
“fit”) was also found to be a contributor to housing stability in the
qualitative analysis. Individuals identified in the unstable housing group also indicated
knowing more people and having more contact with them, as well
as reporting higher levels of satisfaction with their circumstances
Participants with Additional than individuals achieving stable housing in the first year. A
or Other Needs possible explanation for these differences is that individuals in the
In general, despite the fact that participants had diverse unstable housing group had more difficulty detaching themselves
ethnocultural and demographic backgrounds and different from their social networks, which were made up of other
circumstances, HF participants were able to achieve housing individuals who are homeless or unstably housed.
stability. For example, HF worked about equally well among
As well, individuals in the unstable housing group were more
men and women, and was particularly effective among older
likely to be assessed as having a psychotic disorder (45 per
participants; younger participants were slightly less likely to
cent) and less likely to be assessed as having a panic disorder
remain in stable housing. Moreover, those with substance use
(24 per cent) or post-traumatic stress disorder (31 per cent). This
problems at baseline maintained stable housing to a similar
is compared to individuals in the stable housing group who
degree as the overall sample.
were assessed with a psychotic disorder (35 per cent), panic
However, even though the majority of HF participants became disorder (15 per cent), or post-traumatic disorder (20 per cent).
stably housed, housing stability was not achieved for a small However, this group was similar to those who achieved stable
group (13 per cent). This group was found to have longer lifetime housing in many other ways. Notably, there were no differences
histories of homelessness, to be less likely to have completed high in terms of gender, ethnic origin, diagnosis of depression,
school, to report a stronger sense of belonging to their street social substance use, arrests, contact or detention by police, or

FIGURE
Figure 4.4.Days
Daysin in emergency
emergency shelters
shelters by studyby study
group andgroup
type of and type of program
program.

50 ACT ANALYSIS HF TAU

50 ICM ANALYSIS HF TAU

40 40

30 30
Days

Days

20 20

10 10

0 0
0 3 6 9 12 15 18 21 24 0 3 6 9 12 15 18 21 24
Months Months
19
community functioning. This underscores the importance of Winnipeg involved the use of transitional apartments on one floor
considering need on an individual basis and the complexity of of a secure residential apartment building for those who had to
trying to predict the subgroup of individuals who will encounter learn how to prevent unwanted guests from intruding and creating
continued housing instability while receiving HF services. difficulties with neighbours and for the tenant. This confirms that
further adaptations of the model are warranted and feasible. The
Some alternative approaches to addressing the unique housing
adaptations of the HF approach in Winnipeg and Moncton showed
needs of these participants were piloted during the course of
this responsiveness to need while still maintaining a high level of
the study. For example, in Moncton, peer-staffed congregate
the fidelity to the main domains of the HF model (e.g., housing
housing was found to be necessary for some of those who
choice and structure, separation of housing and clinical services).
had additional needs and were not doing well in independent
More detail is provided in site reports.
apartments despite several relocations. Another approach in

HF in its classic format is not a panacea — a small number of

individuals’ mental health and medical needs, and/or level of
functioning are such that they are best served in living arrangements
where a more intense level of support and more structure can
be provided.

Over 260 landlords and property management companies were involved.

Landlord Engagement
The HF approach is unique among housing interventions in that units are sought from, in most cases, private sector landlords. Feasibility
and effectiveness of the model depends on the ability to engage landlords and respond to their concerns. Over the course of the study,
over 260 landlords and property management companies participated in the study, which is quite remarkable given the vacancy rates and
the flexibility landlords generally have in terms of tenant choice. Only a minority opted to leave the program. Qualitative data about their
experiences was collected from 57 landlords. We found that across sites, these landlords relayed positive relationships with the At Home/
Chez Soi housing and clinical teams, as well as positive relationships with tenants. In Moncton, landlords stated that program tenants were,
in many instances, as good as or better than other tenants. Landlords in Vancouver had positive experiences with the “fit” of tenants in
their buildings, and landlords in Winnipeg talked about having good relationships with the housing team despite considerable tenancy
challenges. The takeover of apartments by former acquaintances, who then engaged in drug and alcohol related activities that were
disruptive for the tenant and neighbours and damaged the property, is an example of a tenancy challenge that support staff and landlords
had to manage. Much was learned about how to work in partnership with landlords and these learnings are outlined in the forthcoming
Housing First Toolkit.
In summary, the At Home/Chez Soi study has demonstrated substantially improved housing stability for participants across all five
cities and in both program types, compared to those receiving existing housing and mental health services. The quality of housing
was similar or better than that of individuals in the TAU group that found housing. More is now known about the small proportion of
intervention participants for whom housing stability did not ensue, and several adaptations to address their needs were explored. The
majority of recruited landlords stayed involved with the programs, and while there were housing challenges, their experiences on the
whole seemed to be positive.

20
 CHAPTER 5
SERVICE USE AND COST OUTCOMES

One of the advantages of stable housing for a group who have high levels of chronic mental and physical illness is the possibility of
shifting their care from institutions and crisis-related services to more appropriate planned visits and regular follow-up with community
-based services. In this chapter, we examine the research questions: What is the impact of HF on health, social, and justice/legal
system service use and costs? Does continued investment in HF, as one innovative solution to chronic homelessness, make
sense from social and economic perspectives?

At each interview, HF and TAU participants were asked standard the types of health and social services used, which are illustrated
questions about all the types of health, social, and justice services for both need groups in the following four graphs. Both HF and
they had accessed in the previous time period. Since these TAU groups reported declines in emergency room (ER) visits
findings are not the main outcomes of the study and have not (Figure 5) with lower levels among HF participants over the course
been formally tested statistically, and self-report information of the study. This difference was mostly attributable to the MN
might be inaccurate due to imperfect recall, the findings reported group in relation to TAU. HF participants also had lower levels of
in this chapter are a first round. They will be complemented visits to hospitals for outpatient care (these included day hospital
by additional analyses currently underway to examine the visits but not visits for laboratory or diagnostic tests) shown in
service use differences in greater detail, including the use of Figure 6. Differences in outpatient visits were very large for HN
administrative data received directly from health and justice participants and moderate for MN participants.
service providers in each province.
Lower use of drop-in centres for meals and other services needed
by participants was also noted for the HF group (Figure 7);
Health Service Use however, the use of food banks appeared to be higher for both
In Chapter 4, we noted substantial reductions in overnight stays HN and MN participants (Figure 8). This is not surprising, given
in shelters and institutions (hospitals, prisons, jails, and addiction that many food banks require a fixed address in order to provide
treatment facilities). We also found some encouraging patterns in a hamper. Also, housed individuals were able to store food and

FIGURE 6. Outpatient Visits

FIGURE
Figures5. ER Visits
5 and 6. Shifts away from ER services and outpatient visits.

2.5 ER VISITS HF TAU 2.5 OUTPATIENT HF TAU

2.0 2.0
Number of Visits
Number of Visits

1.5 1.5

1.0 1.0

0.5 0.5
0 6 12 18 End 0 6 12 18 End
Months Months

21
FIGURE 7. Drop-in Centres FIGURE 8. Food Banks
Figures 7 and 8. Differences in drop-in centre and food bank use

DROP-IN CENTRES HF TAU FOOD BANKS HF TAU

80 3.5
70 3.0
60

Number of Visits
Number of Visits

2.5
50
2.0
40
1.5
30
1.0
20
10 0.5

0 0
0 6 12 18 End 0 6 12 18 End
Months Months

prepare meals. Across sites, many HF participants found that Justice Service Use
having stable housing (and, for many, associated financial stability)
Over the complete follow-up period, contact with the justice
was paramount to improving their eating patterns, since they
system was common for both the HF and TAU groups. During
could finally purchase and store food and supplies for themselves.
this period, the majority (89 per cent) had at least one interaction
Given that community-based service delivery by providers (e.g. with police officers, which could involve help-seeking, information
in-person visits and phone calls) was an intentional and essential requests or criminal activity. Around one third of participants
part of the intervention, we expected to find greater frequencies of were actually arrested during the study timeframe. Both HF and
these events in the HF group relative to TAU, and that is what was TAU groups reported substantial declines in their contacts with
found. The details of these service patterns are not provided here, justice services (police, security services, courts, and other justice
but they are included in the comprehensive economic analysis in services), with no significant difference between the groups. When
the next section. reasons for arrests were investigated, however, HF participants
In this chapter, the findings presented are based on self- reported fewer arrests for public nuisance offences and drug-
reported health service use. Because self reports and related offences over time, whereas TAU participants reported
administrative records do not always paint the same picture, no such decline. This is consistent with the increase in residential
we have made initial comparisons between HF and TAU stability for HF participants, who might then be less likely to be
groups regarding the similarity of information collected arrested for engaging in activities meeting basic needs, such as
from these two sources for three sites (Winnipeg, Montréal sleeping in public spaces or washing in public bathrooms.
and Vancouver).* In these analyses, we examined days in There are several possible reasons for the small effect of HF
hospital, emergency room visits, and ambulance trips. on study participants regarding justice contacts. First, justice-
Although the number of events reported by participants was involved individuals with mental illness are not a homogeneous
often lower or higher than the number of events in administrative group. In fact, there are distinct subgroups. HF, as implemented,
records, there do not appear to be any important differences did not specifically target criminal justice involvement; there
between the HF and TAU groups in these reporting differences may be benefit in further adaptations to suit the specific
over the study period and across these three sites. This means that needs of legally involved participants. Second, criminal justice
we can have confidence that the comparisons between groups in involvement is complex and a proportion of service events (e.g.,
the self-report data are reasonably valid. More analysis on health court appearances) may be attributable to criminal behaviour
service use outcomes based on administrative data is in progress that occurred several months or even years before the study
and will be reported separately in 2014. began. For example, we noted that some participants were
arrested because of warrants for offences that occurred in the
past. A two-year follow-up period might not be sufficient to show

*Members of the validation analysis committee are acknowledged for this work, and can be contacted for further details. They are Mark Smith, Carol Adair,
Brianna Kopp, Laurence Katz, Daniel Rabouin, Julian Somers, Akm Moniruzzaman, Angela Ly, Guido Powell, and Jimmy Bourque.

22
 the downstream effects of housing stability on justice system
involvement. Finally, data thus far is limited to self-report; a team
Thus, every $10 invested in
of study investigators is currently in the process of accessing
and analyzing administrative data from courts, police services,
HF services resulted in an
corrections, and forensic services across the country, and more average reduction in costs of
definitive findings will be provided subsequently.
other services of $9.60 for HN
Cost Analysis participants and $3.42 for MN
As noted earlier in this report, the HF intervention had important
effects on the types of services that participants used: fewer participants.
nights in shelters, fewer ER visits, greater use of food banks, etc.
By housing participants, HF obviously has a direct impact on justice services, such as shelters, drop-in centres, physician visits,
emergency shelter use. HF also has indirect effects on the use and police arrests, welfare and disability income, and any offsetting
of other services. Being housed, with their own kitchen, yet with employment income.
low incomes, HF participants would be expected to make greater As illustrated in Figures 9 and 10, by comparing the costs of
use of food banks. A person who is more stable and better cared services incurred by HF participants with TAU participants over
for is less likely to need to go to an ER, but regular contact with the two-year period following participant study entry, and by
a consistent clinical team may also lead to appropriate receipt of taking into account differences in costs that existed between the
health care, for example, which might not happen if they were still groups at baseline, we estimate that receipt of HF services for HN
homeless. In addition, the HF clinical teams may help participants participants resulted in average reductions of $21,375 in the cost
access welfare or disability benefits. Being housed and benefiting of other services being used by this group. For MN participants
from the regular, holistic care that HF teams offer may also receiving HF services, we found an average reduction of $4,849
ultimately result in HF participants increasing their participation in in the cost of other services being used. Thus, every $10 invested
the labour force, reducing their need for public support. in HF services resulted in an average reduction in costs of other
At the same time, the HF intervention itself is costly: $22,257 per services of $9.60 for HN participants and $3.42 for MN participants.
person per year on average for HN/ACT participants and $14,177 TAU participants also experienced reductions in costs after study
per person per year for MN/ICM participants. These costs include entry. This is similar to the findings for housing stability (Chapter 4),
salaries of all front-line staff and their supervisors, additional community functioning and quality of life (Chapter 6). Participants
program expenses such as travel, rent, utilities, etc., and rent were recruited to the study at a time when most were in crisis;
supplements. The intervention for HN participants is more costly and, most TAU participants also accessed services, so a natural
because, while an ICM team, as implemented in At Home/Chez Soi, reduction in severity of circumstances is to be expected.
includes one case manager for at least every 16 participants, the
While costs went down for both groups, the reduction in the costs
ACT team includes one service provider for every 10 participants.
of services other than the intervention itself was greater for the HF
It is then natural to ask how overall costs, including those of the groups. Total costs avoided arise from a combination of decreased
intervention, as well as those of resources such as shelters, change costs for some types of service use (cost offsets), and, to a much
when a person starts to receive HF services. To address this smaller extent, increased costs for others. These offsets, along
question, we took into account, in a comprehensive way, the costs with one significant increase, are illustrated in Figures 11 and 12. For
of the HF intervention, as well as those of other social, health and HN participants, the greatest cost offset is an estimated reduction

Figure 9. Annualized average costs per person for HN participants, by Figure 10. Annualized average costs per person for MN participants,
FIGURE 9.
experimental group, baseline vs experimental study period. by experimental group, baseline vs experimental study period.
FIGURE 10.
Average Cost per Moderate Needs Person

$100,000
Average Cost per High Needs Person

TAU HF HF Costs TAU HF HF Costs

$80,000

$60,000

$40,000

$20,000

0
BASELINE 0 - 24 MONTHS BASELINE 0 - 24 MONTHS

23
FIGURE 11.
Emergency Home Visits Jail / a psychotic disorder, and a history of
Office visits Hospital
(Non-Study) (Physical) Shelter (Non-Study) Prison more hospitalizations, but lower suicide
0 risk. When they were recruited, these
participants had been incurring costs on
Average Cost per High Needs Person

average at a rate of about $225,000 per

$(1,000) year per person. In this top 10 per cent,
both HF and TAU groups experienced
a very large reduction in costs during
$(2,000) study follow-up, but the reduction was
clearly greater for the HF group. In fact,
the reduction is more than twice as
$(3,000) great as the cost of the intervention
itself: for this group of participants,
every $10 invested in an HF intervention
$(4,000) resulted in $21.72 in avoided costs.
The total costs offset for this group, along
with one significant increase, are illustrated
$(5,000)
in Figure 14. The most significant cost
offset is psychiatric hospitalizations: the HF
Figure 11. Annualized average cost offsets per person for HN participants. intervention is able to prevent subsequent
psychiatric hospitalizations to a much
greater extent than usual services. This
of about $4,700 in the costs of non- per cent of this high service use group is not surprising, as many studies have
study office visits (not including hospital was made up of HN participants and 33 shown that ACT teams, in particular, are
outpatient clinics but including visits to per cent was MN. This group was similar consistently effective at reducing both
doctors in their own office, and visits to to the full sample in many ways numbers of admissions and length of
community clinics). The costs of the HF – 55 per cent were between 35 and 54 stay for people who tend to spend a
intervention, have thus partially replaced years old, 65 per cent were male, 47 per considerable amount of time in psychiatric
the costs of such services that participants cent had less than a high school education, wards.19 At the same time, this high cost
normally receive. For MN participants and their income and prior employment group tended to have more stays in
receiving HF, in contrast, this type of cost status are similar, yet a smaller proportion psychiatric residential facilities.
increases, on average, by slightly more of this group is Aboriginal. In terms of
Overall, from a cost perspective, HF services
than $1,000 per participant per year. homelessness history, they were more
have substituted for other services, notably
Because ICM teams do not include any likely to be absolutely homeless at study
hospitalizations, emergency shelters, jail/
medical personnel, this result suggests that enrolment but did not have as long a
prison, and home or office visits to different
case managers on ICM teams facilitated period of homelessness as the rest of the
providers. On average, the intervention
access to such services. In fact, this is sample. They were more likely to have
comes close to paying for itself among
consistent with the role of case managers
who provide ICM and assist individuals
with access to needed services.
As shown, cost offsets are much greater Figure 12. Annualized average cost offsets and increases per person for MN participants.
FIGURE 12.
for HN participants, even considering the
cost of the intervention. This pattern was Emergency SRO Office visits
consistent across the sites (more detail Shelter (with support) (non-study)
$1,500
is available in site reports). We attribute
Average Cost for Moderate Needs Person

this finding to greater opportunities for $1,000

changing costly service use patterns in HN
participants, given their higher service use $500
levels at study entry.
This finding suggests that, if services were 0
focused on participants who cost the most
at baseline, the cost offsets would be even $(500)
greater, and might even exceed the cost of
$(1000)
the intervention. We identified the 10 per
cent of participants who cost the most at
$(1500)
baseline (i.e., in the year prior to entering
the study). It is important to note that 67
$(2000)

24
 $250,000 patient, and the hospital may see no

Average Cost per Person of top 10% HN

TAU HF Non HF
difference in its expenditures. Nonetheless,
a costly resource has been freed, which
$200,000 benefits another patient; the gap between
available supply and demand has been
$150,000 decreased slightly. Second, we estimated
unit costs taking into account not only the
portion of costs borne by governments,
$100,000 but also those covered by private
donations and even some volunteering,
particularly for homeless shelters. Thus,
$50,000
the reduction in use of shelters may partly
benefit government funders, and partly
0 private donors and volunteers. Third, while
BASELINE 0 - 24 MONTHS the great majority of the avoided costs
benefit provincial governments (often
Figure 13. Comparison of TAU group and HF group cost offsets on annualized average different ministries, such as justice and
costs per person for 10 per cent of participants with highest costs at baseline. health, within a provincial government),
some benefit municipal governments
and the federal government (e.g.,
federal penitentiaries). Even so, real cost
HN participants, but the cost offsets are cost users could easily pay for itself, but
reductions in some types of service use,
more modest for MN participants. That the would miss meeting the needs of these
such as shelters, are probably achievable
intervention does not more than pay for other vulnerable participants.
and allow for reallocation if HF is part of a
itself, on average, should not be surprising
It should be noted that “paying for itself” comprehensive homelessness strategy.
as people were recruited to the study on
in this context does not mean that a
the basis of need, not on the basis of how Finally, the duration of our study was
government that paid for HF services
costly they were. As a result, some of the only two years. We do not know whether
would see a corresponding reduction in
people recruited were highly marginalized a longer follow-up period would have
its expenditures on other services. There
and were not accessing shelters and other increased or decreased the magnitude
are at least three reasons for this. First,
services at study entry. The analysis of the of cost offsets, for a given group of
if HF prevents an individual from being
effects of the intervention for the most participants. However, some of our results
hospitalized, for example, the hospital
costly 10 per cent of participants at baseline suggest that the cost offsets would
bed that this person does not occupy
indicates that targeting HF services at high increase over time. Detailed analysis of
will almost inevitably, be filled by another

Figure 14. Annualized average cost offsets and increases per person for the 10 per cent of participants with highest costs at baseline.
y)

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h

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yc

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ith

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ts
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Average Cost per High Needs Person

$(5,000)

$(10,000)

$(15,000)

$(20,000)

25
the qualitative interviews in particular of costs as well as of other outcomes, mental illness, most had chronic physical
indicates that the lives of participants and each site is currently undertaking health conditions, a substantial proportion
receiving HF services were, for the most a four-year follow-up with results to be had substance-related problems, and
part, improving. As their lives become reported in peer reviewed publications. many had underlying cognitive and
more ordered, many may need less learning disabilities at the beginning of
In summary, using information reported
intensive clinical supports. Some may the study. These service use changes
by participants, we found some very
become able to re-integrate into the translated into some very promising
substantial differences in patterns of
labour force and, as such, not only no patterns of cost shifts, with most cost
some types of service use. The overall
longer need welfare or disability benefits, offsets seen for higher need participants
picture is that the HF intervention (for
but also contribute to the economy and a subgroup with the highest service
both need groups) produces more
through their work. Their physical and use costs at study entry.
appropriate community-based service
mental health may stabilize. Longer-
use and better responsiveness to the
term follow-up of the participants would
needs of participants, all of whom were
provide valuable information in terms
experiencing homelessness and living with

26
 CHAPTER 6
SOCIAL AND HEALTH OUTCOMES

At the time of enrolment into the study, the average At Home/Chez Soi participant had experienced homelessness for a total of about
five years, and most had an even longer history of social and physical disadvantage — often reaching back to early childhood. Street
and shelter life is harsh, and most activities of daily living are centred on basic survival: finding food, shelter, and places to rest; avoiding
harassment and victimization; and, for some, seeking and using substances as a way to cope. These circumstances are not conducive to
participating in treatment for mental health or addictions issues, or to managing physical health problems. For some, improvement after
becoming stably housed can be rapid. For most, however, recovery is gradual, and often halting. In this chapter, we report findings for the
research question: How has HF affected participants’ quality of life, community functioning, and mental and physical health?

Quality of Life and Community Functioning

To measure quality of life, we used the quality of life that the HF group did. While subscale), but only in the ICM group.
Quality of Life Index (QOLI 20), which encouraging, these differences are not as For this subscale, we saw no difference
is based on participant self-report. To large as the differences in housing stability, between TAU and HF among the people
measure community functioning, we used but they were examined using statistical receiving ACT. There was also no evidence
the Multnomah Community Ability Scale tests and can be considered due to the that the intervention improved interviewer-
(MCAS), which is based on observation by intervention and not a chance occurrence. rated mental or physical health items
a research assistant (more details of the on the MCAS; there were improvements
The largest treatment effect on functioning
methods for this chapter can be found in in this area, but they were the same in
was on the “behaviour” scale of the MCAS,
Appendix A). HF and TAU. Men tended to have more
which includes items on cooperation with
improvement on the MCAS compared to
Based on these scales, improvements in treatment providers (including medication
women, but the MCAS scores for women
community functioning and quality of life compliance), substance use, and impulse
in both TAU and HF were very similar,
were somewhat greater in HF than in TAU control. Participants’ ability and willingness
resulting in little treatment effect. We also
for the total cross-site group. The study to interact with others, as measured by
found that participants in their 40s and
documented immediate increases in both, the “social skills” scale, also improved
50s had a bit more improvement in MCAS
followed by more gradual continuing more in the HF group. The intervention
scores than younger participants.
improvements (as shown in Figures 15 and also seemed to improve life skills like
16). TAU participants also improved, but money management, independence, and The intervention improved participants’
did not achieve the levels of functioning or acceptance of illness (the “adaptation” reported quality of life. The biggest

Figure 15. Differences between HF and TAU in Community Figure 16. Differences between HF and TAU in Quality of Life over
FIGURE 15. over the Study Period.
Functioning the Study
FIGURE 16. Period.

HF TAU HF TAU
70
90
66
85
64
MCAS Score

QoLI Score

80
62

60 75

58 70
0 6 12 18 End 0 6 12 18 End
Months Months

27
change was, unsurprisingly, in the “living”
subscale, which asks about satisfaction
Getting people into housing represents
with their homes and neighbourhoods.
We also saw smaller group differences
an important success, however, and we
in perceived safety and in satisfaction were able to show that it does produce real
with finances, which may also be directly
related to the provision of housing. There improvements in community functioning
were fewer signs that the intervention
improved participants’ satisfaction with and quality of life. We hope that sustained
their social lives or relationships with
family; as elsewhere, these things did
improvements in mental health and
improve, but they improved by about
the same amount in HF and TAU. In
substance use will follow.
general, the effects of the intervention
were slightly larger among the MN group Health and Substance- people in) and contact with care providers
may simply have begun the process.
than the HN group. This was especially Related Outcomes Getting people into housing represents an
true for the items on leisure activities We saw improvements in participants’ important success, however, and we were
and perceived safety. Some variation in mental health and substance-related able to show that it does produce real
quality of life and community functioning problems (based on the Colorado Symptom improvements in community functioning
outcomes is seen for specific programs Index [CSI] for mental health and the Global and quality of life. We hope that sustained
in specific sites and is further elaborated Assessment of Individual Needs Substance improvements in mental health and
in the site reports. We did not find Problem Scale [GAIN SPS] [see Appendix substance use will follow.
differences in quality of life by sex or age. A]), but these changes were similar among
participants in all groups. The intervention For most outcomes, we also saw
In summary, although generally both
itself did not seem to hasten improvements improvements in the TAU group. This was
HF and TAU groups improved in these
in these areas over the two years of the expected. Before they entered the study,
measures, the HF groups improved
study. On the other hand, placing people many participants had better and worse
more and more quickly than TAU groups
in housing with no readiness requirements periods — times when they were absolutely
on measures of quality of life (by the
did not put them at higher risk and their homeless and in desperate circumstances,
participants’ own reports) and community
outcomes were as good as those of the and others when they had somewhere to
functioning (by observer’s ratings).
usual care system. stay and were able to function reasonably
The qualitative research allowed well. Most participants were recruited to
participants to tell us, in their own words, There are several possible reasons we did the study in one of their crisis periods. As a
what was happening in the same areas not find greater improvements in these result, we expected to see improvements,
measured by the scales. In general, this areas. From other research, we know that on average, simply because many people
qualitative information showed that the many of these illnesses can be lifelong. would naturally move from the current
quality of participants’ daily lives changed Recovery from these illnesses often emergency to a somewhat better state.
from being survival-oriented to being involves improvement in symptoms, but Statisticians call this “regression to the
“more secure,” “peaceful,” and “less stuck,” it also requires learning to manage those mean,” and it is one of the reasons why it
which enabled them to move forward symptoms in healthy ways. This allows was important to conduct a randomized
in their lives. At baseline, participants people, ultimately, to reclaim important controlled trial: if we randomly decide who
tended to describe their daily lives using social roles (neighbour, family member, gets Housing First, and compare those
phrases such as “killing time” and “shuffling friend, coworker). Housing and services people to a group who don’t, then we can
around.” After becoming housed, they provide the minimum prerequisite for be fairly sure that any differences that
talked about more meaningful activities this kind of recovery, but they do not emerge between the two groups are due
(e.g., “establishing a nice routine” and guarantee that it will immediately follow. to the intervention we provided. If we had
“doing things that matter”). As one Toronto For many people, it is a very long process. no one to compare the HF participants to,
participant stated: “I am really proud of For most participants, symptoms were we would probably end up overestimating
myself, with a lot of help I was…able to…not uncontrolled for many years; two years the program’s effectiveness.
really get back to where I used to be, but in of housing (less, in most cases, as it took
time to locate apartments and move Measures of physical health remained
a better place.”
about the same in both groups over
the course of the study. While access
to physical health care may have been
After becoming housed, they talked about improved by housing and contact with
service teams, it was generally not
more meaningful activities (e.g., “establishing provided directly, and many participants
were already regular users of emergency
a nice routine” and “doing things that matter”) rooms or other services. Many also

28
HF participants were more than twice as likely to have a positive life
course over time, compared with TAU participants. Moreover, TAU
participants were more than four times as likely to show a negative
life course over time. FIGURE 17.

had chronic health problems, like lung 70

TAU HF
conditions, hepatitis C, arthritis and
diabetes, which cannot be rapidly cured 60
and, in some cases, can only be managed
with difficulty. With these chronic illnesses, 50
observing steady state, rather than further

Percentage %
declines, is good news.
40
How Life Courses Differed 30
Between Groups
The information gathered in the qualitative 20
interviews was analyzed by classifying
participants’ stories into one of three life
courses: positive, negative or mixed/neutral
10
(shown in Figure 17). To ensure that these
findings were reliable, classifications were 0
Positive Mixed / Neutral Negative
done by two raters for each participant;
agreement was found to be very good. Participant Feedback
This integrated picture of social and health
outcomes illustrates effects that more Figure 17. Differences between HF and TAU in life courses.
closely match the housing outcomes. HF
participants were more than twice as likely
to have a positive life course over time,
aspects of identity, as well as motivation Factors Related to Positive
for some to “do what it takes” to reclaim
compared with TAU participants. Moreover,
those aspects of their lives, including
Life Courses
TAU participants were more than four Stable housing was an important factor
beginning to “focus on (them)selves” and
times as likely to show a negative life associated with individuals who had
their mental health. It is also important
course over time. positive life courses. The acquisition of
to underscore that these findings reflect
Participants’ comments suggest that group averages. The individual responses stable housing gave participants both
becoming housed spurs hope for in both HF (ICM and ACT) and TAU over hope and confidence, and provided
recovery of both personal and social time were enormously diverse. opportunity for participants to take on new
social roles. A second factor was positive
social contacts, which was multifaceted
and varied across sites. In Toronto,
participants who had positive or improving
relationships with family tended towards
Participants’ comments suggest that positive life courses; the same was true in
Winnipeg of Aboriginal participants who
becoming housed spurs hope for recovery of connected with their cultural traditions

both personal and social aspects of identity, and supportive communities. Across
sites, it was the support garnered from
as well as motivation for some to “do what positive social contacts that was key to
understanding how this factor contributed
it takes” to reclaim those aspects of their to positive life courses. Supportive social
contacts were associated with reduced
lives, including beginning to “focus on (them) substance use. It is difficult to ascertain the

selves” and their mental health. direction of the relationship between these
factors — whether decreased substance

29
 model and recovery, so it is unsurprising was a participant from Vancouver who
that precarious housing is a crucial factor attempted to return to school and resume
associated with negative trajectories. contact with family. Both pursuits did not
Housing stability, quality Negative social contacts and isolation were go well, leaving the participant feeling
of life and community also associated with negative trajectories. depressed and hopeless and subsequently
functioning outcomes While negative social contacts affected self-isolating.
both housed and unhoused participants,
were all more positive for
programs that operated
isolation was typically — although not The Relationship between
exclusively — associated with housed
most closely to the following participants. In both instances, participants
Program Fidelity and Key
HF principles: lacked the supportive social contacts that Study Outcomes
are important in helping to make difficult We examined whether participants in
life changes. Increased or continued programs with higher fidelity had better
Immediate access to heavy substance use was associated with outcomes. Housing stability, quality of life,
1 and community functioning outcomes
housing with no housing
negative trajectories and likely associated
readiness conditions with individuals remaining involved in were all more positive for programs that
social groups who use substances. Finally, operated most closely to HF standards.
Consumer choice and hopelessness was an important factor We also found that participants who
2
self-determination associated with negative trajectories. enrolled later in the study did somewhat
Hopelessness was presented across better, and this may be related to the
sites as the pervasive belief that things increase in program fidelity over time.
3 Recovery orientation
These findings indicate that supporting
would not improve for the individual.
Hopelessness was associated with both all components of the HF model and
Individualized and investing in training and technical support
4 histories of social marginalization as well
person-driven supports as perceived failures and disappointments can pay off in improved outcomes. They
of participants in the face of life challenges. also suggest that somewhat better overall
Social and community
5 One common example scenario that outcomes may be achievable for long-
integration preceded hopelessness was losing running programs; in our study, fidelity
housing. One participant in Vancouver improved as new programs worked out
who faced an eviction presented her problems and gained experience, and
circumstances in the following terms: better fidelity predicted better outcomes.
use was caused by or resulted from “I’m an addict — I screwed up. I was clean This finding also helps to validate the HF
changes in social contacts. It was clear, for eight months and then I relapsed… approach. That is, if the intervention was
however, that reductions in substance use Maybe I’m not good enough to have an not effective, better fidelity to it would not
were associated with positive life courses. apartment. I’m thinking that now.” improve outcomes.
Finally, new social roles were an important
In summary, the findings for health and
factor in positive life courses across sites.
In Vancouver, Toronto, and Moncton, many
Factors Related to Mixed social outcomes indicate that participants

participants changed their daily activities or Neutral Life Courses in both groups improved after a period
of acute homelessness or crisis. Like the
to include things like volunteering, Mixed trajectories were associated with
housing outcomes, we know that most
coaching softball, working, attending substance use as well as perceived failures
of the TAU participants also had access
school or becoming peer support and disappointments. In this trajectory,
to and received a range of treatment
workers. These activities gave participants participants made uneven progress
interventions in each city, many of which
opportunities to take on new social roles with a split of roughly equal positive
had positive impact. While it appears to
that expressed a positive social identity. and negative gains. Similar to negative
be the case that HF had a similar impact
trajectories, participants with mixed
in mental health and substance use
experiences showed sustained substance
Factors Related to use and setbacks due to relapse. Perceived
problems, the findings on quality of life
Negative Life Courses failures and disappointments is the most
and community functioning indicate that
Precarious housing — losing housing; living HF can produce additional improvements
salient factor associated with mixed
in shelters, housing of poor quality or in broader life domains that hold promise
trajectories. Similar to hopelessness for
unstable housing; or negative experiences for more positive outcomes and recovery
those individuals with negative trajectories,
with housing — was associated across over the longer term.
participants with mixed trajectories often
sites with negative life courses. It should made attempts to make life changes but
be noted that precarious housing might had difficulty following through when
represent uneven implementation of the faced with setbacks. The subsequent
model in sites where the housing stock is cycle of hope and disappointment was
of more variable quality (e.g., Winnipeg). emblematic of mixed trajectories. One
Housing is central to the Housing First salient example of a mixed trajectory

30
CHAPTER 7
IMPLICATIONS FOR PRACTICE AND POLICY

At Home/Chez Soi offers an evidence base to inform effective

HF policy and program development for people experiencing
homelessness and mental health and/or substance use issues.
The knowledge generated
KEY FINDINGS
through this study is now available
and data will continue to be Housing First can be effectively implemented in Canadian cities of different
1 size and different ethnoracial and cultural composition. Across all the five cities,
analyzed and shared to support
HF programs were operated in a manner that was consistent with the HF model
the implementation of evidence- standards, but were tailored to best fit the local contexts. The HF approach was
informed HF programs. There is successfully adapted to serve Aboriginal, immigrant, and other ethnoracial
groups in a culturally sensitive manner. (Chapter 2)
growing momentum across the
country as governments and Housing First rapidly ends homelessness. Across all cities, HF participants in At
communities are considering 2 Home/Chez Soi rapidly obtained housing and retained their housing at a much
how to implement HF programs, higher rate than the treatment as usual (TAU) group. (Chapter 4)

adapt it to their local contexts and Housing First is a sound investment. The economic analysis found some cost
use it to enhance their existing 3 savings and cost offsets. (Chapter 5)
programs and services. A number
It is Housing First, but not Housing Only. The support and treatment services
of communities have already 4 offered by the HF programs contributed to appropriate shifts away from many
implemented HF programs and types of crisis, acute, and institutional services towards more consistent
can continue to expand and community and outreach-based services. This shift supports and encourages
more appropriate use of health and shelter services. (Chapter 5)
strengthen them. In an important
policy shift towards HF, the federal Having a place to live and the right supports can lead to other positive
government renewed funding 5 outcomes above and beyond those provided by existing services. HF
participants also demonstrated somewhat better quality of life and community
for the Homelessness Partnering
functioning outcomes than those receiving existing housing and health services
Strategy with a focus on HF, which in each city. (Chapter 6)
will allow for further development
of HF in Canada. The At Home/ There are many ways in which Housing First can change lives. The HF groups,
6 on average, improved more and described fewer negative experiences than TAU
Chez Soi findings add to this (Chapter 6). Understanding the reasons for differences of this kind will help to
growing Canadian HF expertise tailor future approaches, including understanding the small group for whom HF
by providing strong research did not result in stable housing. (Chapter 4)

evidence and experience in

Getting Housing First right is essential to optimizing outcomes. Housing stability,
implementation to help guide HF 7 quality of life, and community functioning outcomes were all more positive for
policy and program development. programs that operated most closely to Pathways HF standards. (Chapter 6)

31
POLICY IMPLICATIONS
Housing First is an effective,
1 pragmatic, and humane
cost savings. Reductions in the use of
4 To effectively implement
resources by people who are homeless Housing First, partnership and
intervention to address homelessness. can alleviate existing pressures on the collaboration across government,
There are few interventions or strategies respective shelter and health services. communities and service sectors is
designed to address homelessness that These findings are particularly of note in required. The qualitative findings from At
can truly be described as best practices; light of the finding that only 15 per cent of Home/Chez Soi help us understand some
Housing First is one of them. A solid people who are homeless are chronically of the key ingredients needed to
research base provides evidence for the or episodically homeless (the rest are successfully implement HF in Canada. One
effectiveness of the approach. At Home/ transitionally homeless) yet take up over of the vital lessons is that while At Home/
Chez Soi successfully implemented HF in half of homelessness resources such as Chez Soi has demonstrated that Canadian
five cities in Canada and demonstrated emergency shelter beds and communities can successfully implement
that HF has the ability to end day programs.20 HF programs, to fully address the
homelessness for people who are complexity of chronic homelessness in our
chronically homeless and living with To achieve the best outcomes, communities, strong leadership and
serious mental health, addiction, and other 3 HF programs should partnerships across departments, sectors,
complex issues. demonstrate high fidelity to the core government and communities is needed
aspects of the model, even for programs to build bridges across fragmented
Housing First improves access to
2 community services and can
that have been adapted to different systems and programs. At Home/Chez Soi
has examples of the kind of cross-sector
settings. With the increasing interest and
contribute to cost containment. The uptake of HF, there is a risk that HF may collaboration that helped participants
findings from At Home/Chez Soi indicate be defined in different ways and that the navigate across these systems.
that there are measurable cost offsets core principles may be ignored or only
associated with HF. In the area of health partially implemented.21 HF has been Housing First may need to be
care, HF contributes to cost containment defined as having the following core 5 adapted to meet the needs of
as it improves access to needed health elements: immediate access to housing specific sub-populations. We
services and contributes to a shift from with no housing readiness requirements, need to better understand the potential
institutions and crisis-related services to consumer choice and self-determination, benefits and challenges of implementing
more appropriate and planned visits and recovery orientation (including harm Housing First with other populations who
regular follow-up with community-based reduction), individualized and client-driven are at risk of homelessness (e.g., families,
services. HF, therefore, helps to ensure supports, and social and community women, seniors, youth, or those
more appropriate use of hospital and integration).22 At Home/Chez Soi experiencing short-term homelessness).
community health care resources. demonstrated that adherence to the core The basic principles of Housing First show
Actual cost savings are more likely to HF principles, with room for adaptation, promise for application to these other
be achieved in shelter expenditures was an element of program success. A groups, but variations in the model may be
with the expansion of the Housing First key element of fidelity is the capacity to warranted, such as adjusting the
model within a larger strategy to end deliver strong, evidence-based services composition of the service and support
homelessness, leading to decreases in and supports. At Home/Chez Soi found teams to meet the needs of the population
chronic homelessness and potentially less that housing stability, quality of life, and served. It will be beneficial to better
need for shelter beds. Given the pressures community functioning outcomes were understand who benefits from Housing
that growing community populations all more positive for programs that First and who does not, and if variations to
with high unmet needs place upon operated most closely to HF standards. the model are needed for other groups.
acute and inpatient health services, it is Understanding the core elements of HF Further work is required to determine the
difficult for beds to be closed and dollars is an important element of program best approaches to respond to
to be shifted to other sectors. In smaller development and implementation, and homelessness among the approximately
locations where there is a critical mass of investing in ongoing training and 13% of people who are not successful with
HF capacity, the closure of shelter beds technical support and program traditional Housing First interventions.
may be realized more quickly. In larger evaluation/quality assessment can
urban areas, it may be more reasonable pay off in improved outcomes.
to talk about cost avoidance rather than

32
 WHAT’S NEXT?
Policies and funding that To support communities interested in implementing Housing First, the lessons learned
6 address the lack of affordable from At Home/Chez Soi and other Canadian HF programs have now been incorporated
housing (including HF and rent into a toolkit to guide the planning and implementation of effective Housing First programs
supplements) across the nation is in Canada; this toolkit will be available in the Spring 2014. The Mental Health Commission of
needed to end homelessness in Canada. Canada is also working with partners to develop and offer training and technical assistance
At Home/Chez Soi was implemented to a number of communities interested in implementing Housing First.
successfully in each of the five sites, using In the future, the MHCC website will be a central mechanism for the dissemination
a rent supplement approach. Participants of At Home/Chez Soi reports and articles. We are also actively engaged with other
were largely able to choose the homelessness and mental health forums to share knowledge. The Final Report provides
neighbourhood and type of housing they a high-level view of a multi-faceted project and more detailed analysis will continue to be
wanted, as At Home/Chez Soi was done for scientific papers (e.g., two-year outcomes for the Assertive Community Treatment
grounded in the HF principle of choice and and Intensive Case Management service delivery models will be submitted for publication
self-determination as the foundation of shortly). Local Site Reports are also available and report on the unique characteristics and
recovery. HF operates on the assumption program outcomes in their settings.
that people know their own needs best,
including where they want to live and the
kinds of services they would like to access.
Our findings in At Home/Chez Soi are CONCLUSION
consistent with the evidence that housing
choice improves housing stability and At Home/Chez Soi demonstrated that implementing HF in Canada is possible and that
quality of life and that, given a choice, there are benefits for the people who receive HF as well as for the service system and
many would choose to live in independent the community. The many service and housing providers who worked on At Home/Chez
permanent housing over congregate/ Soi developed new skills and increased the capacity in their communities for the delivery
social housing models.23 This suggests that of recovery-oriented services. Out of necessity, the project brought together community
the development of a full range of housing providers, stakeholders and governments from across sectors to work together around
and support options that include rent a complex issue — providing HF for people with serious mental health issues who are
supplements would allow people to direct experiencing homelessness. While some questions remain regarding HF, it has well
their own opportunities and find a place to demonstrated its potential and At Home/Chez Soi has and will continue to contribute to
call home that best suits their needs. the growing Housing First expertise in Canada and internationally.
However, communities across Canada,
including the five At Home/Chez Soi Sites,
are facing a lack of access to affordable
housing generally and, in particular, a lack
of access to good quality, affordable,
independent units for people experiencing
“Now that my kids are in my life and [the At
mental illness and homelessness. For the
expansion of HF across Canada to be
Home service team] brought me into the
successful and to be able to end program and helped me out, I’m very grateful
homelessness in our communities, access
to good quality, affordable housing needs for whoever came up with this idea of (at)
to be improved across the country.
home, helping homeless people and I’m
hoping and praying that they find other ways
to keep things going like this, cause there is a
lot of people still hurting right and…I still see
them out there…and struggling.”
(Winnipeg Participant)

33
REFERENCES
1
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian
Homelessness Research Network Press. http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf

2
Hwang, S.W., Wilkins, R., Tjepkema, M., O'Campo, P.J., Dunn J.R. Mortality among residents of shelters, rooming houses, and hotels in
Canada: 11 year follow-up study. Bmj. 2009;339:b4036. BMJ. 2009; 339: b4036.

3
Centre for Addiction and Mental Health, Canadian Council on Social Development (2011): Turning the Key: Assessing Housing and Related
Supports for Persons Living with Mental Health Problems and Illness. Mental Health Commission of Canada.
http://www.mentalhealthcommission.ca/English/node/562?terminitial=23

4
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian
Homelessness Research Network Press. http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf

5
Canadian Homelessness Research Network (2012) Canadian Definition of Homelessness. Homeless Hub: www.homelesshub.ca/
CHRNhomelessdefinition/

6
Goering, P., Tomiczenko, G., Sheldon, T., Boydell, K., & Wasylenki, D. (2002). Characteristics of persons who are homeless for the first time.
Psychiatric Services, 53(11), 1472–1474.

7
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian
Homelessness Research Network Press. pg 28 http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf

8
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian
Homelessness Research Network Press. http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf

9
Stephen Gaetz, Fiona Scott, & Tanya Gulliver (2013). Housing First in Canada. http://www.homelesshub.ca/ResourceFiles/Documents/
HousingFirstInCanada.pdf

10
Paula Goering, Scott Veldhuizen, Aimee Watson, Carol Adair, Brianna Kopp, Eric Latimer and Angela Ly. (2012). At Home/Chez Soi
Interim Report. Mental Health Commission of Canada. http://mentalhealthcommission.ca/English/document/5032/home-interim-
report?terminitial=38

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Paula Goering, Scott Veldhuizen, Aimee Watson, Carol Adair, Brianna Kopp, Eric Latimer and Angela Ly. (2012). At Home/Chez Soi
Interim Report. Mental Health Commission of Canada. http://mentalhealthcommission.ca/English/document/5032/home-interim-
report?terminitial=38

12
To access the qualitative reports go to http://mentalhealthcommission.ca/English/initiatives-and-projects/home. 1. Conception of the
Mental Health Commission of Canada’s At Home/Chez Soi Project: Cross-Site Report; 2. Planning and Proposal Development for the
Mental Health Commission of Canada’s At Home/Chez Soi Project: Cross-Site Report; 3. Implementation and Fidelity Evaluation of the
Mental Health Commission of Canada’s At Home/Chez Soi Project: Cross-Site Report; 4. Follow-up Implementation and Fidelity Evaluation
of the Mental Health Commission of Canada’s At Home/Chez Soi Project: Cross Site Report.

13
Statistics Canada. Canada's Ethnocultural Mosaic, 2006 Census. Ottawa: Statistics Canada; 2008.

14
Canada Mortgage and Housing Corporation. Online Definitions http://cmhc.beyond2020.com/HiCODefinitions_EN.html#_Core_Housing_
Need_Status

34
15
Vicky Stergiopoulos, Carolyn Dewa, Janet Durbin, N Chau, T Svoboda. (2010). Assessing the mental health service needs of the homeless:
a level-of-care approach. Journal of Health Care Poor Underserved, 21(3); 1031-45.

16
Blakely, C.H., Mayer, J.P., Gottschalk, R.G., Schmitt, N., Davidson, W.S., Roitman, D.B., & Emshoff, J.G. (1987). The fidelity-adaptation debate:
Implications for the implementation of public sector social programs. American Journal of Community Psychology, 15, 253-268.

17
Hawe, P., Shiell, A., & Riley, T. (2004). Complex interventions: How ‘‘out of control’’ can a randomised controlled trial be? British Medical
Journal, 328, 1561–1563.

18
Tsemberis, S. (2010). Housing First: The Pathways model to end homelessness for people with mental illness and addiction. Center City,
MN: Hazelden.

19
Latimer, E. Economic Impacts of Assertive Community Treatment: A Review of The Literature. Canadian Journal of Psychiatry.
1999;44(5):443-54.

20
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian
Homelessness Research Network Press. http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf

21
Pleace, N., & Bretherton, J. (2012). What do we mean by Housing First? Categorising and critically assessing the Housing First movement
from a European perspective. Paper presented at the European Network for Housing Research, Lillehammer, Norway.; Johnson, G.,
Parkinson, S., & Parsell, C. Policy shift or program drift? Implementing Housing First in Australia, AHURI Final Report No. 184. Melbourne:
Australian Housing and Urban Research Institute.

22
Stephen Gaetz, Fiona Scott, Tanya Gulliver (2013). Housing First in Canada. Canadian Homelessness Research Network (Homeless Hub).
http://www.homelesshub.ca/ResourceFiles/Documents/HousingFirstInCanada.pdf)

23
Community Treatment Approaches for Homeless Adults with Concurrent Disorders: What Works for Whom, Where, Why, and How?
Summary of a Realist Approach to Evidence Synthesis. Centre for Research on Inner City Health. May 2009. Available at www.crich.ca;
Myra Piat, Alain Lesage, Richard Boyer, Henri Dorvil, Audrey Couture, Guy Grenier, David Bloom (2008). Housing for Persons with serious
mental illness: Consumer and Service Provider Preferences. Psychiatric Services 59(9), 1011-1017. http://psychiatryonline.org/data/Journals/
PSS/3857/08ps1011.pdf

35
APPENDIX A
OVERVIEW OF STUDY DESIGN AND METHODS

Study Design
The At Home/Chez Soi study design is a randomized controlled pragmatic field trial.1 Randomized means that participants were put
into the Housing First (HF) intervention and treatment as usual (TAU) groups by chance. A computer program was used to assign
participants to the study groups at random, with no influence by the study investigators, service providers, sponsors or anyone else. By
controlled we mean that a “control” or comparison group that does not receive the intervention is used to make sure that any changes
observed are due to the intervention and not some other influence. The term pragmatic means that the study involved individuals that
would ordinarily present for a HF service in practice and that the services they and the TAU group received may vary as they would in
real world circumstances. Finally, by field trial we mean that the intervention occurred in the same settings that the services might later
be implemented if found to be effective. The study was also, by design, “multi-site” — that is, it was conducted in multiple sites — with four
larger urban settings and one smaller urban/rural setting so that more could be learned about how HF programs fit or can be adapted
to local contexts.

Why a randomized controlled trial? quantitative sample, except for having a slightly higher income
at baseline in the qualitative subsample; the demographic
Although there were a range of options for study designs, a
characteristics of TAU and HF groups were also equivalent.
randomized controlled trial was chosen because it is the best
design for showing that participant changes are due to the 2,148 individuals were enrolled and, of those, 1,158 received the HF
intervention. This is because randomizing makes the two groups intervention. Follow-up rates, defined as all those who completed
virtually equal on anything other than the intervention that could at least one interview instrument at their final interview were
produce the outcomes. As such, a randomized controlled trial between 77 and 89 per cent and as high as 91 per cent in one site,
provides the strongest evidence for decision making. which are excellent for a vulnerable and often transient population
(see Table A1 for details). These figures include those lost to follow-
up for all reasons including the 85 participants known to have died
How were data collected and how many
during the study period. An analysis is currently underway using
participants completed data collection? national mortality statistics to get complete information on the
Data collection included interviews with participants at baseline number of deaths and the causes of death.
and every three months for up to two years of follow-up, plus
information from the programs (such as the number of service
visits), and from national and provincial administrative data
What type of information was collected?
sources for health and justice service use before and after the A comprehensive range of information was collected in the
beginning of the study. The first participant was enrolled in study at all sites including demographic information (such as
October 2009 and the last interview ended in June 2013. All age, sex and education), homelessness and service use history
participants were screened and grouped into high and moderate (e.g., emergency room visits, hospital admissions, jail stays, court
need groups (see Appendix D for definitions) before being
randomized to HF and TAU groups. Participants were given
Table A1 – Follow-up Rates by Program
honoraria (around $20 – 30) at each interview to encourage
continued participation. Data were entered using laptops in NATIONAL COMPLETED FINAL INTERVIEW?
the field to a highly secure national database approved by
Research Ethics Boards at all sites. Data collection included both NO YES %
quantitative (information based on numbers) and qualitative TAU in ACT analysis 112 369 77%
(information based on text and stories) approaches. Qualitative HF in ACT analysis 58 411 88%
methods complement the quantitative findings and enhance
TAU in ICM analysis 115 394 77%
their interpretation. For the qualitative component, a sample of
participants were interviewed in depth at the beginning of the HF in ICM analysis 73 616 89%
study and at the 18-month point. One hundred and ninety-seven All TAU 227 763 77%
participants from both HF and TAU groups, roughly every 10th All HF 131 1027 89%
participant, were interviewed at both points. This sample was
demographically similar in almost all respects with the overall Study Total 358 1790 83%

36
appearances), adverse childhood experiences, mental and physical that represent specific categories of functioning/disability and
health status (including chronic illnesses and history of brain the proportions of our study participants who fell into each are
injury), work and income-related information, and extensive service outlined in Table A2.
cost information. The study is also the first to include a measure
While the other main instruments consist of questions answered
of Recovery and an observer-rated housing quality measure, to
by participants, the MCAS is completed by the interviewer, based
document in detail the role of peer support and fidelity to the
on information collected through interviews, observed behaviour
program model, respectively (see Appendix C).
and current life circumstances. This approach was taken to ensure
The primary outcomes measured at all sites were housing that outcomes reflected both participants’ perspectives and
stability, community functioning, and quality of life. Key objective ratings by study research staff.
secondary outcomes were mental illness and substance use
Quality of Life – We measured participants’ feelings about their
problems. These five variables are described in greater detail
quality of life with the Quality of Life Index (QOLI-20),4 which asks
below. Interested readers are referred to the study protocol
about satisfaction with family relationships, social relationships,
at the first reference below for greater detail on the full range
finances, leisure, living situation, and safety. This instrument was
of measures, and to the site reports for more information on
developed and validated with individuals with long-term mental
additional site-specific data.
health issues.
Housing (RTLFB) – information on the types and locations of
Mental Illness Symptoms – We assessed symptoms of mental
stays (including any type of shelter or crisis housing, temporary
illness using the Colorado Symptom Index (CSI),5 a scale developed
or longer-term residences and street locations) for every day
and validated for people experiencing homelessness. The CSI asks
during the study period were collected every three months
how often in the past month the participant experienced problems
using the Residential Time-Line Follow-Back (RTLFB) instrument.2
like depression, anxiety, strange behaviour, and poor concentration.
This involves the use of a calendar to systematically guide the
participant in recalling all the locations and types of housing that Substance Use Problems – To measure substance use problems,
he or she has resided in during the prior period. The RTLFB was we used the short version of the Global Assessment of Individual
developed for and has been validated in HF programs and clients. Needs Substance Problems Scale (GAIN SPS).6 The GAIN SPS asks
It was modified slightly to reflect the Canadian context. people how recently they experienced problems like withdrawal,
spending a lot of time finding or using substances, or getting into
Community Functioning (MCAS) – to assess community
trouble because they were intoxicated.
functioning, we used the Multnomah Community Ability Scale
(MCAS),3 a 17-item scale that covers mental and physical health,
ability to cope with illness, social skills, and problem behaviours. Analysis Methods for Primary Outcomes
The MCAS was developed and validated for individuals with long- The following analytic methods were used for the purposes
term mental health issues and related disability. It produces a total of this report for housing stability, quality of life, and
score that has total scores ranging from 17 to 85. Score ranges community functioning.

Table A2. Categories of Disability on the MCAS and Percentages Overall and by Study Need Level

DISABLITY LEVEL ALL HN MN

High (Score less than 47) 9% 18% 2%
Moderate (Score of 48–62) 45% 75% 20%
Low (Score of 63–85) 46% 7% 78%
HIGH

LOW
HIGH
HIGH
MODERATE

LOW
MODERATE
MODERATE LOW

All Participants High Moderate

Disability Needs Disabilty Needs Disability Needs

37
To analyze housing stability, quality of life, and community 400 distinct unit costs were estimated. In many cases, service
functioning outcomes, we used mixed effects modeling. Mixed providers were contacted to obtain their financial and activity
effects models make it possible to measure the associations reports and to help interpret them. When a program's expenditures
between outcomes and predictor variables while taking into included contributions by private donors as well as government
account the non-independence of observations. (In this case, non- sources, we included the value of private contributions as this
independence is present because there are multiple interviews for represents the full cost of service delivery from the point of view
each participant. Less importantly, participants were also grouped of society. Welfare and disability payments were included as
into treatment arms and cities.) they represent costs that society must incur in order to enable
individuals who are homeless to participate in and benefit from
In each model, the main predictor of interest was group
Housing First programs and other existing housing programs.7
membership: whether a participant had been randomized to HF
Income from employment was subtracted from overall costs
or TAU. In national-level models, we also controlled statistically for
as this represents the value of a contribution to society by the
age, sex and the variables that played a role in determining the
individual. Estimates of capital costs were included in all services.
group assignment: city, aboriginal status, ethnoracial status and
All costs were expressed in fiscal year 2010 – 2011 Canadian dollars.
need level. We treated time as a categorical variable, essentially
Due to the two-year follow-up period, we did not apply discounting.
estimating group differences and treatment effects at every time
point. To test group differences, we interacted the time and group
variables, which produces estimates of group differences at each Analysis Methods for Clients with
time point. Additional or Other Needs
To measure the overall effect of the intervention, we considered A focused analysis was also undertaken on individuals in the HF
(1) the group difference at the end of the study (after taking any group for whom housing stability was not achieved (13 per cent).
baseline differences into account); and (2) the average difference This group was made up of HF participants who were housed less
across all interviews conducted after baseline. The first measure than 50 per cent of the time during the last nine-month period of
reflects the treatment effect at the last time point available for each the first year and not housed 100 per cent of the time in the last
person. The second reflects the overall benefit, if any, realized over three months of the first year. Time in institutions such as jail or
the entire course of the two-year study. Because we performed hospital was removed from total days for the calculation. Only HF
an interim analysis with a p value of 0.01, we set the significance participants who had at least six months of housing history data
threshold at 0.04 in the final report. in the last nine months of the first year or had not been in jail or
hospital for 66 per cent of the last nine months of the first year
were considered in these analyses. Differences on demographic
Analysis Methods for Costing characteristics, clinical characteristics, quality of life, community
The economic analyses were conducted from the point of view integration, and community functioning at baseline and cognitive
of society. Service use and residential questionnaires enabled us functioning at six months between those individuals failing to
to assess quantities of a wide range of services used, as well as of achieve housing stability and individuals who were considered
income from various sources. We estimated unit costs (e.g., the stably housed in the first year of the study were examined.
average cost of an emergency room visit, of a police arrest, of a Findings of statistically significant between-group differences on
night in a shelter) city-by-city using the best available data. Nearly these variables are reported.

REFERENCES | APPENDIX A
1
Goering P.N., Streiner D.L. # See http://bmjopen.bmj.com/content/1/2/e000323.full

2
New Hampshire Dartmouth Rehabilitation Center. (1995). Residential Follow-back Calendar [version June 1995]. Lebanon, N.H. Dartmouth
Medical School.

3
Barker, S. Barron, N. McFarland, B.H., et. al. (1994). A community ability scale for chronically mentally ill consumers. Community Mental
Health Journal, 30, 459-472.

4
Lehman, A.F. (1996). Measures of quality of life among persons with severe and persistent mental disorders. Social Psychiatry and
Psychiatric Epidemiology, 31, 78-88.

5
Boothroyd, R.A., Chen, H.J. (2008). The psychometric properties of the Colorado Symptom Index. Journal of Administration and Policy in
Mental Health and Mental Health Services Research, 35(5), 370-378.

6
Dennis, M.L., Chan, Y., Funk, R.R. (2006). Development and validation of the GAIN Short Screener for internalizing, externalizing, and
substance use disorders and crime/violence problems among adolescents and adults. The American Journal on Addictions, 15, 80-91.

7
Weisbrod BA, Test MA, Stein LI: Alternative to Mental Hospital Treatment: II. Economic Benefit-Cost Analysis. Archives of General Psychiatry
37:400-5, 1980.

38
 APPENDIX B
HOUSING-RELATED STATISTICS FOR
AT HOME/CHEZ SOI SITES
STATISTIC MONCTON MONTRÉAL TORONTO WINNIPEG VANCOUVER
Vacancy rate (%) (mid-study– Spring 2011)1 4.1 2.5 1.6 .7 2.8
% homes in core housing need 2009 2
9* 13.1 17.8 9.5 20.5
Average rent for a one-bedroom $583 $626 $969 $657 $934
apartment (mid-study – Spring 2011)1

1
Rental Market Statistics, Canada Mortgage and Housing Corporation, Spring 2012 (reporting on April 2011 values)
http://www.cmhc-schl.gc.ca/odpub/esub/64725/64725_2012_B01.pdf?fr=1388695801870

2
Core housing need means housing does not meet one or more of the adequacy, suitability, and affordability standards (30 per cent
before-tax income to pay median rent incl. utilities); figures from Canadian Housing Observer, Canada Mortgage and Housing Corporation,
2012. http://www.cmhc-schl.gc.ca/odpub/pdf/67708.pdf
* only available for NB as a whole

39
 APPENDIX C
FIDELITY ASSESSMENT METHODS AND SCALE

An important component of study methods was the measurement of how “true” the programs were to the principles and practice of
Housing First (also called fidelity). These fidelity assessments were conducted with all the At Home/Chez Soi ACT and ICM teams in the
five sites by a team made up of clinicians, researchers, housing experts, and a consumer representative. In site visits conducted near
the end of the first year of the study and again one year later, the team reviewed data from multiple sources including interviews with
staff, observation of program meetings, chart reviews, and consumer focus groups. A Housing First fidelity scale with versions for ACT
and ICM program types was developed for the study, and used to rate programs on 38 items (listed below), including, for example,
working effectively with hospital staff for people admitted as inpatients, using a harm-reduction approach to substance use, and
allowing participants to help choose their housing. Each ACT and ICM team received a report about the assessment findings, including
recommendations for improvement on standards where full implementation was not achieved.
Overall, there was good fidelity to the Housing First model: 71 per cent of items in the first round, and 78 per cent in the second, were rated
3 or 4 on a 4-point scale (the meaning of these ratings varies by item, but this corresponds generally to a “good” level of performance).

FIDELITY ITEM ACT FIDELITY SCALE ICM FIDELITY SCALE

HOUSING CHOICE & STRUCTURE
1. Housing Choice. Program participants choose the location and other X X
features of their housing.
2. Housing Availability. Extent to which program helps participants move X X
quickly into units of their choosing.
3. Permanent Housing Tenure. Extent to which housing tenure is assumed X X
to be permanent with no actual or expected time limits, other than those
defined under a standard lease or occupancy agreement.
4. Affordable Housing. Extent to which participants pay a reasonable amount X X
of their income for housing costs.
5. Integrated Housing. Extent to which program participants live in scatter- X X
site private market housing which is otherwise available to people without
psychiatric or other disabilities.
6. Privacy. Extent to which program participants are expected to share living X X
spaces, such as bathroom, kitchen or dining room with other tenants.
SEPARATION OF HOUSING AND SERVICES
7. No Housing Readiness. Extent to which program participants are not X X
required to demonstrate housing readiness to gain access to housing units.
8. No Program Contingencies of Tenancy. Extent to which continued X X
tenancy is not linked in any way with adherence to clinical, treatment, or
service provisions.
9. Standard Tenant Agreement. Extent to which program participants have X X
legal rights to the unit with no special provisions added to the lease or
occupancy agreement.
10. Commitment to Re-House. Extent to which the program offers X X
participants who have lost their housing access to a new housing unit.
11. Services Continue Through Housing Loss. Extent to which program X X
participants continue receiving services even if they lose housing.
12. Off-site, Mobile Services. Extent to which social and clinical service X X
providers are not located at participant’s residences and are mobile.

40
FIDELITY ITEM ACT FIDELITY SCALE ICM FIDELITY SCALE
SERVICE PHILOSOPHY
13. Service choice. Extent to which program participants choose the type, X X
sequence, and intensity of services on an ongoing basis.
14. No requirements for participation in psychiatric treatment. Extent to which X X
program participants with psychiatric disabilities are not required to take
medication or participate in psychiatric treatment.
15. No requirements for participation in substance use treatment. Extent X X
to which participants with substance use disorders are not required to
participate in treatment.
16. Harm Reduction Approach. Extent to which program utilizes a harm X X
reduction approach to substance use.
17. Motivational Interviewing. Extent to which program staff use motivational X X
interviewing in all aspects of interaction with program.
18. Assertive Engagement. Program uses an array of techniques X X
to engage consumers who are difficult to engage, including
(1) motivational interventions to engage consumers in a more
collaborative manner, and (2) therapeutic limit-setting interventions
where necessary, with a focus on instilling autonomy as quickly as
possible. In addition to applying this range of interventions, (3) the
program has a thoughtful process for identifying the need for assertive
engagement, measuring the effectiveness of these techniques, and
modifying approach where necessary.
19. Absence of Coercion. Extent to which the program does not engage in X X
coercive activities towards participants.
20. Person-Centered Planning. Program conducts person-centered planning, X X
including: (1) development of formative treatment plan ideas based
on discussions driven by the participant’s goals and preferences, (2)
conducting regularly scheduled treatment planning meetings, (3) actual
practices reflect strengths and resources identified in the assessment.
21. Interventions Target a Broad Range of Life Goals. The program X X
systematically delivers specific interventions to address a range of life
areas (e.g., physical health, employment, education, housing satisfaction,
social support, spirituality, recreation & leisure, etc.).
22. Participant Self-Determination and Independence. Program increases X X
participants' independence and self-determination by giving them choices
and honoring day-to-day choices as much as possible (i.e., there is a
recognition of the varying needs and functioning levels of participants, but
level of oversight and care is commensurate with need, in light of the goal
of enhancing self-determination).
SERVICE ARRAY
23. Housing Support. Extent to which program offers services to help X X
participants maintain housing, such as offering assistance with
neighborhood orientation, landlord relations, budgeting and shopping.
24. Psychiatric Services. Psychiatric services are directly provided by X Program successfully links participants
the program. who need psychiatric support with a
psychiatrist in the community.
25. Integrated, Stage-Wise Substance Use Treatment. Integrated, stage-wise X Program successfully links participants
substance use treatment is directly provided by the program. Core who need substance use treatment with
services include: (1) systematic and integrated screening and assessment; such treatment community.
interventions tailored to those in (2) early stages of change readiness
(e.g., outreach, motivational interviewing) and (3) later stages of change
readiness (e.g., CBT, relapse-prevention).
26. Supported Employment Services. Extent to which supported employment X Supported employment services are
services are provided directly by the program. Core services include: provided directly or brokered by the
(1) engagement and vocational assessment; (2) rapid job search and program.
placement based on participants’ preferences (including going back to
school, classes); & (3) job coaching & follow-along supports (including
supports in academic settings).

41
FIDELITY ITEM ACT FIDELITY SCALE ICM FIDELITY SCALE
27. Nursing Services. Extent to which nursing services are provided directly X Nursing/Medical care. Program
by the program. Core services include: (1) managing participants’ successfully links participants who need
medication, administering & documents medication treatment; medical care with a physician or clinic in
(2) screening consumers for medical problems/side effects; (3) the community.
communicating & coordinating services with other medical providers;
(4) engaging in health promotion, prevention, & education activities
(i.e., assess for risky behaviors & attempt behavior change).
28. Social Integration. Extent to which services supporting social integration X X
are provided directly by the program. (1) Facilitating access to and helping
participants develop valued social roles and networks within and outside
the program, (2) helping participants develop social competencies to
successfully negotiate social relationships, (3) enhancing citizenship and
participation in social and political venues.
29. 24-Hour Coverage. Extent to which program responds to psychiatric or X X
other crises 24-hours a day.
30. Involved in Inpatient Treatment. Program is involved in inpatient treatment X X
admissions and works with inpatient staff to ensure proper discharge.
PROGRAM
31. Priority Enrollment for Individuals with Obstacles to Housing Stability. X X
Extent to which program prioritizes enrollment for individuals who
experience multiple obstacles to housing stability.
32. Contact with Participants. Extent to which program has a minimal X X
threshold of non-treatment related contact with participants.
33. Low Participant/Staff Ratio. Extent to which program consistently X X
maintains a low participant/staff ratio, excluding the psychiatrist &
administrative support.
34. Team Approach. Extent to which program staff function as a X N/A
multidisciplinary team; clinicians know and work with all
program participants.
35. Frequent Meetings. Extent to which program staff meet frequently to plan X
and review services for each program participant.
36. Daily Meeting (Quality): The program uses its daily organizational X Weekly Meeting (Quality): The program
program meeting to: (1) Conduct a brief, but clinically-relevant review of uses its weekly organizational program
all participants & contacts in the past 24 hours AND (2) record status meeting to: (1) Conduct a high level
of all participants. Program develops a daily staff schedule based on: overview of each participant, where
(3) Weekly Consumer Schedules; (4) emerging needs, AND (5) need for they are at and next steps (2) a detailed
proactive contacts to prevent future crises; (6) Staff are held accountable review of participants who are not doing
for follow-through. well in meeting their goals (3) review of
one success from the past week and (4)
program updates and (5) discuss health
and safety issues and strategies.
37. Peer Specialist on Staff. The program has at least 1.0 FTE staff member X Peer Specialist on Staff. The program
who meets local standards for certification as a peer specialist. If peer has at least 1.0 FTE staff member who
certification is unavailable locally, minimal qualifications include the meets local standards for certification
following: (1) self-identifies as an individual with a serious mental illness as a peer specialist.
who is currently or formerly a recipient of mental health services; (2) is in
the process of his/her own recovery; and (3) has successfully completed
training in wellness and recovery interventions. Peer specialist has full
professional status on the team.
38. Participant Representation in Program. Extent to which participants are
represented in program operations and have input into policy.

42
APPENDIX D
KEY DEFINITIONS
Eligibility Need Level
Inclusion Criteria: High need must have:
• Legal adult status (aged 18 or older/19 A score on the Multnomah Community Ability Scale (MCAS) of 62 or lower (functioning
in British Columbia) indicator) AND a Mini International Neuropsychiatric Interview (MINI) diagnosis of
current psychotic disorder or bipolar disorder (MINI disorders 18, 21 or 22 on the Eligibility
• Housing status as absolutely homeless
Screening Questionnaire) or an observation of psychotic disorder on the screener (at least
or precariously housed*
two of Q 6e10 in Section DI) on the Eligibility Screening Questionnaire (diagnostic indicator)
• The presence of a serious mental AND one of:
disorder^ with or without a co-
existing substance use disorder, • YES (or don’t know or declined) to item 20 on Demographics, Service & Housing
determined by DSM-IV1 criteria on the History questionnaire; that is, two or more hospitalizations for mental illness in any one
Mini International Neuropsychiatric year of the last five (service use indicator) OR Comorbid substance use (any of MINI
Interview (MINI)2 at the time of disorders 23, 24, 25 or 26 on the Eligibility Screening Questionnaire) (substance use
study entry indicator) OR recent arrest or incarceration.
• YES (or don’t know or declined) to item 22 on Demographics, Service & Housing
Exclusion Criteria: History questionnaire (legal involvement indicator).
• Currently a client of another ACT
or ICM program Moderate need
• No legal status as a Canadian citizen, • All others who have met eligibility criteria but do not meet the criteria above.
landed immigrant, refugee or
refugee claimant
• Those who are relatively homeless*

Absolutely Homeless / Precariously Housed*

Absolute homelessness Relatively homeless
Homelessness refers to those who lack a regular, fixed, physical This includes people whose regular housing fails to meet basic
shelter. This (conservative) definition is known as absolute standards, such as: (1) living in overcrowded or hazardous
homelessness, according to the United Nations, and includes those conditions; (2) those at risk of homelessness, such as people who
who are living rough in a public or private place not ordinarily reside informally/non-permanently with friends or relatives (e.g.,
used as regular sleeping accommodation for a human being (e.g., doubling-up, couch surfing); (3) those in transition (e.g., women,
outside, on the streets, in parks or on the beach, in doorways, youth fleeing to transition houses/shelters from domestic abuse);
in parked vehicles, squats, or parking garages), as well as those (4) those who are temporarily without a dwelling (e.g., home lost
whose primary night-time residence is supervised public or private for a relatively short period of time due to disasters such as a fire,
emergency accommodation (e.g., shelter, hostel).iii Specifically, or a change in economic or personal situation, such as marital
being homeless is defined as currently having no fixed place to separation or job loss; and, (5) those living in long-term institutions.
stay for more than seven nights and little likelihood of obtaining iii The UN definition of homelessness originally included individuals in
accommodation in the upcoming monthiv or being discharged transition using transition homes and hostels. The present project modified
the definition to exclude this subgroup.
from an institution, prison, jail or hospital with no fixed address.
iv Definition adopted from Tolomiczenko, G. and Goering, P.3

Precariously housed Serious mental disorders^

This refers to people whose primary residence is a Single Room Serious mental disorders are defined by diagnosis, duration, and
Occupancy (SRO), rooming house or hotel/motel. In addition, disability using observations from referring sources, indicators
precariously housed individuals in the past year have had two or of functional impairment, history of recent psychiatric treatment,
more episodes of being absolutely homeless, as defined above, in and current presence of eligible diagnosis as identified by the
order to meet the criteria for inclusion. Mini International Neuropsychiatric Interview (major depressive,
manic or hypomanic episode, post-traumatic stress disorder, mood
disorder with psychotic features, psychotic disorder).

43
Stable Housing
Stable housing was defined as living in one’s own room, apartment, or house, or with family, with an expected duration of residence greater
than or equal to six months and/or tenancy rights.

REFERENCES FOR APPENDIX D

1
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC.

2
Sheehan, D.V., Lecrubier, Y., Harnett-Sheehan, K., Amorim, P., Janavs, J., Weiler, E., Hergueta, T., Baker, R., Dunbar, G. The Mini International
Neuropsyciatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview. Journal of Clinical
Psychiatry, 1998; 59(suppl 20):22-33.

3
Gender differences in legal involvement among homeless shelter users. Int J of Law and Psychiatry 2001;24:583e93. There are gender
differences in legal involvement among homeless shelter users.

44
APPENDIX E
DETAILS OF THE SAMPLE:
Demographic Characteristics, Homeless History, Past and Current Personal,
Health, and Social Circumstances

Table 1 – Participant Demographic Characteristics*

TOTAL SAMPLE ACT ANALYSIS ICM ANALYSIS

N =2148 N =950 N =1198
% % %
AGE GROUPS
34 or younger 33 39 29

35–54 57 54 59
55 or older 10 7 12
GENDER
Male 67 68 66

Female 32 31 33
Other 1 1 1
COUNTRY OF BIRTH
Canada 81 85 78
Other 19 15 22
Ethnic status^
Aboriginal 22 19 24
Other ethnocultural 25 21 28
Marital status
Single, never married 70 73 68
Married or common-law 4 4 4
Other 26 23 28
Parent status
Any children 31 30 32
Education
Less than high school 55 59 52
High school 19 19 18
Any post-secondary 26 22 30
Prior military service (for Canada or an ally) 4 4 4
Prior month income less than $300 24 24 25
Prior employment (worked continuously at least one year in the past) 66 62 69
Currently unemployed 93 94 92
* all information was reported by participants except where noted
^ many values will not reflect proportions in the general homeless population due to deliberate oversampling of some groups in some sites

45
Table 2 – Homelessness History*

TOTAL SAMPLE ACT ANALYSIS ICM ANALYSIS

N =2148 N =950 N =1198
% % %
HOMELESS STATUS AT ENROLMENT
Absolutely homeless** 82 79 84
Precariously housed 18 21 16
FIRST TIME HOMELESS
The year prior to the study 23 19 26
2008 or earlier 77 81 74
LONGEST PERIOD OF HOMELESSNESS IN MONTHS 31 34 29
(lowest and highest rounded to next month) (0–384) (1–384) (0–360)
TOTAL TIME HOMELESS IN LIFETIME IN MONTHS 58 62 55
(lowest and highest rounded to nearest month) (0–720) (0-460) (0–720)
AGE FIRST HOMELESS
31 28 37
(lowest and highest rounded to nearest month) (1-70) (1–69) (4–70)

* all information was reported by participants except where noted

** See http://bmjopen.bmj.com/content/1/2/e000323.full or Appendix D for definitions of absolutely homeless and precariously housed

46
Table 3 – Past and Current Personal, Health, and Social Circumstances*

TOTAL SAMPLE ACT ANALYSIS ICM ANALYSIS

N =2148 N =950 N =1198
% % %
NEED LEVEL (DETERMINED BY STUDY SCREENING)
High need 38 87 0
Moderate need 62 13 100
ADVERSE CHILDHOOD EXPERIENCES (ACE)
Mean score (out of a possible 10) 4.6 4.5 4.7
COGNITIVE IMPAIRMENT
Got extra help with learning in school 41 45 39
Has a learning problem or disability 34 37 32
DIAGNOSIS AT ENROLMENT
Psychotic disorder
34 52 22

Non-psychotic disorder 71 60 79
Substance-related problems 67 73 62
SUICIDE RISK AT ENROLMENT
Moderate or high 36 36 36
COMMUNITY FUNCTIONING AT ENROLMENT
(rated by interviewers)
Average MCAS score% 60 54 65
(lowest and highest scores) (33 – 80) (33 – 80) (37 – 79)
HOSPITALIZED FOR A MENTAL ILLNESS &

(for more than 6 months at any time in the past 5 years) 6 12 2

HOSPITALIZED FOR A MENTAL ILLNESS &

(2 or more times in any one year in the past 5 years) 37 54 24

SERIOUS PHYSICAL HEALTH CONDITIONS
Asthma 24 24 25
Chronic bronchitis/emphysema 18 18 18
Hepatitis C 20 22 19
Hepatitis B 3 2 3
HIV/AIDS 4 3 4
Epilepsy/seizures 10 14 7
Heart disease 7 7 7
Diabetes 9
3 11 8
Cancer 3 3 2
TRAUMATIC BRAIN/HEAD INJURY
Knocked unconscious one or more times 66 67 66
JUSTICE SYSTEM INVOLVEMENT
(arrested > once, incarcerated or served probation in prior 6 months) 36 43 30

* all information was reported by participants except where noted

% Multnomah Community Ability Scale – reported by interviewers based on observations, interview responses and collateral information – higher scores
indicate better functioning; a score of 62 and below represents moderate to high disability or moderate to poor functioning; items include daily living
independence, money management, coping with illness, and social effectiveness
& self-report of psychotic disorders and related hospitalizations are likely to be underestimates due to the nature of the illness

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