MHCC Research Demonstration Projects

on Mental Health and Homelessness:Toronto Proposal

Vicky Stergiopoulos, MD, MHSc, FRCPCMedical Director, Inner City Health Associates

Research Scientist, Centre for Research on Inner City HealthSt. Michael’s Hospital

Today’s presentation

BackgroundProject Overview

Housing and Support ServicesResearch

Toronto proposalProgress to dateUnique features

Project governanceNext steps

Background

Growing numbers of homeless across Canada.High prevalence of mental illness, substance use and chronic physical conditions.Many different subgroups with different needs, e.g. youth, seniors, immigrants, indigenous people.Chronically homeless have highest level of need and account for largest proportion of service and societal costs.

True or False?

"... most homeless choose that condition because of drug or alcohol abuse or mental impairment."

Fact

The Toronto Street Needs Assessment revealed that 9/10 homeless clients interviewed in Toronto would like to be housed.

City of Toronto, 2006

True or False?

A homeless person with a mental illness has little chance of recovery.

Fact

Treatment and housing placement of homeless mentally ill individuals has been associated with:

Reductions in psychiatric hospitalizationsDecreased psychiatric symptoms and substance useImproved neuropsychological functioning Lower healthcare costs

Steidman, 2002

Dickey, 2000

MHCC Research Demonstration Projects

Supported by funding agreement between the MHCC and Health Canada.

Multi-site, four year demonstration projects in Vancouver, Winnipeg, Toronto, Montreal and Moncton.

Randomized controlled trials “to provide policy relevant evidence about what service and system interventions best achieve housing stability and improve health and well being for those who are homeless and mentally ill”.

MHCC Research Demonstration ProjectsAdditional Objectives

Effective approaches to integrating housing supports and the basket of necessary services.Development of best practices and Lessons Learned.Identification of unique problems and solutions for diverse ethno-cultural groups.Legacy of improved system integration and support.Enhanced service and evaluation capacity.

MHCC Research Demonstration ProjectsHousing First Philosophy

Housing First creates a recovery oriented culture that puts consumer/tenant choice at the centre of all its considerations.

Rent supplements are provided so that participants pay 30% or less of their income for housing.

MHCC Research Demonstration ProjectsHousing First Model

Housing in self-contained units, mostly private sector and scattered site, with a $600/month rental allowance.

Treatment and support services are voluntary, individualized, culturally appropriate and are based off site.

No conditions on housing readiness.

Tenancy is not tied to engagement in treatment.

Requirements: rent paid directly to the landlord, once a week visits by follow-up supports for pre-determined period.

MHCC Research Demonstration ProjectThe Study Participants

Eligibility18 years or older.Is homeless or precariously housed with a history of absolute homelessness in the past year.Has a serious mental illness, but does not require formal diagnosis at time of referral.

Eligible clients will be randomized to the study interventions or care as usual.

MHCC Research Demonstration ProjectThe Interventions High Needs Group

Recovery Oriented Assertive Community Treatment (Pathways Model).Client/staff ratio of 10:1 or less and includes psychiatrist, nurse.Program staff are closely involved in hospital admissions and discharges.Teams meet daily and include at least one peer specialist as staff.Seven day a week, 24 hr crisis coverage.

MHCC Research Demonstration ProjectThe Interventions

Moderate Needs GroupIntensive case management for a minimum of one year once housed (Streets to Homes Model).Client/staff ratio of 20:1 or less.Integrated efforts across multiple workers and agencies possible.Centralized assignment and monthly case conferences.Seven day a week, 12 hours per day coverage.

MHCC Research Demonstration ProjectsTreatment as usual

Homeless individuals will be eligible to access the array of local services and supports.Will not receive any of the service interventions funded by the MHCC.Can receive similar services as available.

MHCC Research Demonstration ProjectThe Research

A pragmatic, multi-site field trial of the effectiveness and costs of a complex community intervention using mixed methods.

Evaluation dimensions:Formative EvaluationProcess EvaluationImpact EvaluationLinked Studies

MHCC Research Demonstration ProjectThe Research

Data will be collected at baseline and then every six months for the following two years.

Domains of interest include: housing; health status; substance use; quality of life; functioning; healthcare system use and costs; justice system use and costs.

Will be supplemented by four qualitative research reports on the following:

the planning and proposal development phase.the personal stories of consumers at baseline.the implementation of the intervention.the personal stories of consumers at the 18-month follow-up.

The Toronto Proposal

Toronto ProposalBackground

Toronto Street Needs Assessment: a minimum of 5,052 homeless on April 19, 2006:

72% in shelters16% outdoors5% in hospitals and treatment facilities3% in correctional facilities3% in assaulted women’s shelters

Over 30,000 shelter users per year.Toronto population poses unique challenges, given its cultural diversity.

Toronto ProposalThe Leads

Collaborative proposal development.Research Coordinator: Centre for Research on Inner City Health, St. Michael’s Hospital.Service Coordinator: Shelter Support and Housing Administration Division, City of Toronto.Broad and meaningful community participation, in line with core principles of equitable decision-making.Proposal submitted on January 30, 2009:

http://torontomhccproject.ning.com

Toronto ProposalSample Size

Five Groups to be recruited- 560 people in total.

200 people assessed to have high needs100 to receive ACT, 100 to receive usual care

360 people assessed to have moderate needs100 to receive ICM, 100 to receive ethno-specific ICM, 160 to receive usual care

320 people from immigrant and ethno-racial communities.

Toronto ProposalRecruitment Strategy

Multiple points of entry, including:Shelters -75%Streets - 17%Health Care Facilities – 6%Post incarceration – 3%

Referrals from a continuum of service providers.Research coordinator mobile in the community to meet with clients.Intake with service provider within 5 business days.

Toronto ProposalHousing Strategies

Support offered by the City or its agent

Offer a menu of housing options

Support to bring on individual housing units

Administrate payments to landlords

Assist with last month’s rent

Budget for furnishings

Toronto ProposalUnique Research Elements

Physical HealthFacilitated access to primary care for all study participants.Primary care utilization, access to preventive care, selected physiological measures.

Third ArmEthno-specific ICM, using Housing First principles.Collaborative development of model of care.Does it work? How does it work? For whom does it work?

Toronto ProposalKnowledge Translation

A variety of knowledge dissemination tools will be used, including:

Web-based networking site www.torontomhccproject.ning.comSector outreach initiativesRegular Project Town Hall meetingsAnnual MHCC Learning SymposiumProject NewsletterAdditional communication media

Toronto ProposalGovernance

Site Operations TeamPeople with Lived Experience Caucus?

Toronto Advisory Committee

National Advisory CommitteeConsumer Advisory Committee

Site Coordinator

Toronto ProposalPeople with Lived Experience

The knowledge of Persons With Lived Experience (PWLE) will directly inform:

service implementation.equitable representation of PWLE in the oversight and governance of this project.development of local research questions and local methods for gathering and interpreting data.approaches for informing local and national stakeholder communities. approaches for sustaining the interventions after the research project is over.

Toronto Proposal Next Steps

Revise / resubmit proposal (End of March?)If successful, submit to the SMH Research Ethics Board for approval (April-August)Establish Site Operations Team (April)Establish Local Advisory Committee (April-May)Hire and train service and research staff, recruit landlords (April-August)Begin Recruitment (September).

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