Cost-Effectiveness of Housing First With Assertive Community Treatment: Results From the Canadian At Home/Chez Soi Trial.

OBJECTIVE: The At Home/Chez Soi trial for homeless individuals with mental illness showed scattered-site Housing First with Assertive Community Treatment (ACT) to be more effective than treatment as usual. This study evaluated the cost-effectiveness of Housing First with ACT and treatment as usual. METHODS: Between October 2009 and June 2011, a total of 950 homeless individuals with serious mental illness were recruited in five Canadian cities: Vancouver, Winnipeg, Toronto, Montreal, and Moncton. Participants were randomly assigned to Housing First (N=469) or treatment as usual (N=481) and followed up for up to 24 months. The intervention consisted of scattered-site Housing First, using rent supplements, with ACT. The treatment-as-usual group had access to all other services. The perspective of society was adopted for the cost-effectiveness analysis. Days of stable housing served as the outcome measure. Retrospective questionnaires captured service use data. RESULTS: Most (69%) of the costs of the intervention were offset by savings in other costs, such as emergency shelters, reducing the net annual cost of the intervention to about Can$6,311 per person. The incremental cost-effectiveness ratio was Can$41.73 per day of stable housing (95% confidence interval=Can$1.96-$83.70). At up to Can$60 per day, Housing First had more than an 80% chance of being cost-effective, compared with treatment as usual. Cost-effectiveness did not vary by participant characteristics. CONCLUSIONS: Housing First with ACT appeared about as cost-effective as Housing First with intensive case management for people with moderate needs. The optimal mix between the two remains to be determined.

Costs of services for homeless people with mental illness in 5 Canadian cities: a large prospective follow-up study.

BACKGROUND: Limited evidence on the costs of homelessness in Canada is available. We estimated the average annual costs, in total and by cost category, that homeless people with mental illness engender from the perspective of society. We also identified individual characteristics associated with higher costs. METHODS: As part of the At Home/Chez Soi trial of Housing First for homeless people with mental illness, 990 participants were assigned to the usual-treatment (control) group in 5 Canadian cities (Vancouver, Winnipeg, Toronto, Montréal and Moncton) between October 2009 and June 2011. They were followed for up to 2 years. Questionnaires ascertained service use and income, and city-specific unit costs were estimated. We adjusted costs for site differences in sample characteristics. We used generalized linear models to identify individual-level characteristics associated with higher costs. RESULTS: Usable data were available for 937 participants (94.6%). Average annual costs (excluding medications) per person in Vancouver, Winnipeg, Toronto, Montréal and Moncton were $53 144 (95% confidence interval [CI] $46 297-$60 095), $45 565 (95% CI $41 039-$50 412), $58 972 (95% CI $52 237-$66 085), $56 406 (95% CI $50 654-$62 456) and $29 610 (95% CI $24 995-$34 480), respectively. Net costs ranged from $15 530 to $341 535. Distributions of costs across categories varied significantly across cities. Lower functioning and a history of psychiatric hospital stays were the most important predictors of higher costs. INTERPRETATION: Homeless people with mental illness generate very high costs for society. Programs are needed to reorient this spending toward more effectively preventing homelessness and toward meeting the health, housing and social service needs of homeless people.

Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial.

IMPORTANCE: Scattered-site housing with Intensive Case Management (ICM) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment. OBJECTIVE: To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services. DESIGN, SETTING, AND PARTICIPANTS: The At Home/Chez Soi project was an unblinded, randomized trial. From October 2009 to July 2011, participants (N = 1198) were recruited in 4 Canadian cities (Vancouver, Winnipeg, Toronto, and Montreal), randomized to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months. INTERVENTIONS: The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of days stably housed during the 24-month period following randomization. The secondary outcome was generic quality of life, assessed by a EuroQoL 5 Dimensions (EQ-5D) health questionnaire. RESULTS: During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites. [table: see text] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group (60.5 [95%CI, 58.6 to 62.5] at baseline and 67.2 [95%CI, 65.2 to 69.1] at 24 months for the intervention group vs 62.1 [95% CI, 59.9 to 64.4] at baseline and 68.6 [95%CI, 66.3 to 71.0] at 24 months for the usual care group, difference in mean changes, 0.10 [95%CI, −2.92 to 3.13], P=.95). CONCLUSIONS AND RELEVANCE: Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months, but did not improve generic quality of life. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN42520374.

Life changes among homeless persons with mental illness: a longitudinal study of housing first and usual treatment.

OBJECTIVE: This study compared the life changes of homeless people with mental illness participating in Housing First or treatment as usual and examined factors related to various changes. METHODS: Semistructured narrative interviews were conducted with 219 participants in five Canadian cities at baseline; 197 were interviewed again at 18 months after random assignment to Housing First (N=119) or treatment as usual (N=78). Interviews were coded across 13 life domains, and each participant was categorized as reporting positive, mixed-neutral, or negative changes. Housing First and treatment as usual participants were compared with respect to change patterns. Thematic analysis was used to examine factors related to various changes. RESULTS: The percentage of participants in Housing First reporting positive changes was more than double that for participants in treatment as usual, and treatment as usual participants were four times more likely than Housing First participants to report negative changes. Factors related to positive changes included having stable good-quality housing, increased control over substance use, positive relationships and social support, and valued social roles. Factors related to negative changes included precarious housing, negative social contacts, isolation, heavy substance use, and hopelessness. Factors related to mixed-neutral changes were similar to those for participants reporting negative changes but were less intense. CONCLUSIONS: Housing First with intensive support was related to more positive changes among homeless adults with mental illness across five Canadian cities. Those with poor housing or support, more common in treatment as usual, continued to struggle. These findings are relevant for services and social change to benefit this population.

Patterns and predictors of attrition in a trial of a housing intervention for homeless people with mental illness.

PURPOSE: Participant retention is an important challenge in longitudinal research on homeless people. High attrition can threaten validity, and may represent lost opportunities to deliver interventions. In this article, we report on attrition in the At Home/Chez Soi study, a multi-site randomized controlled trial of a housing intervention for homeless people with mental illness. METHODS: We first calculate life tables, and then use clustered logistic regression to implement a discrete-time survival model. We use splines and indicator variables to capture non-linear and group-specific variation over time in the hazard function. As potential predictors, we consider study group, site, date of recruitment, age, sex, baseline substance dependence, baseline psychotic disorder, time homeless in life, community functioning, and education. RESULTS: The study recruited 2,148 homeless people with mental illness. Of these, 1,158 were randomized to the housing first intervention (HF), and 990 to treatment as usual (TAU). Excluding 79 people known to have died, attrition was 14%. This proportion was higher in TAU than in HF (21 vs. 8%, p < 0.01). Attrition was significantly lower in one site than elsewhere, and was also lower among those with substance dependence (13 vs. 18%, p < 0.01) and among those enrolled earlier in the study. The hazard varied over time in complex ways. CONCLUSIONS: Results imply that study factors are more important than participant characteristics as determinants of retention, and that the immediate period after randomization is a crucial one. The high overall retention demonstrates the effectiveness of existing techniques for retaining participants.

Cognitive interviewing methods for questionnaire pre-testing in homeless persons with mental disorders.

In this study, cognitive interviewing methods were used to test targeted questionnaire items from a battery of quantitative instruments selected for a large multisite trial of supported housing interventions for homeless individuals with mental disorders. Most of the instruments had no published psychometrics in this population. Participants were 30 homeless adults with mental disorders (including substance use disorders) recruited from service agencies in Vancouver, Winnipeg, and Toronto, Canada. Six interviewers, trained in cognitive interviewing methods and using standard interview schedules, conducted the interviews. Questions and, in some cases, instructions, for testing were selected from existing instruments according to a priori criteria. Items on physical and mental health status, housing quality and living situation, substance use, health and justice system service use, and community integration were tested. The focus of testing was on relevance, comprehension, and recall, and on sensitivity/acceptability for this population. Findings were collated across items by site and conclusions validated by interviewers. There was both variation and similarity of responses for identified topics of interest. With respect to relevance, many items on the questionnaires were not applicable to homeless people. Comprehension varied considerably; thus, both checks on understanding and methods to assist comprehension and recall are recommended, particularly for participants with acute symptoms of mental illness and those with cognitive impairment. The acceptability of items ranged widely across the sample, but findings were consistent with previous literature, which indicates that "how you ask" is as important as "what you ask." Cognitive interviewing methods worked well and elicited information crucial to effective measurement in this unique population. Pretesting study instruments, including standard instruments, for use in special populations such as homeless individuals with mental disorders is important for training interviewers and improving measurement, as well as interpreting findings.

Exploring the value of mixed methods within the At Home/Chez Soi housing first project: a strategy to evaluate the implementation of a complex population health intervention for people with mental illness who have been homeless.

OBJECTIVE: This paper is a methodological case study that describes the At Home/Chez Soi (Housing First) Initiative's mixed-methods strategy for implementation evaluation and discusses the value of these methods in evaluating the implementation of such complex population health interventions. TARGET POPULATION: The Housing First (HF) model is being implemented in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton. INTERVENTION: At Home/Chez Soi is an intervention trial that aims to address the issue of homelessness in people with mental health issues. The HF model emphasizes choices, hopefulness and connecting people with resources that make a difference to their quality of life. A component of HF is supported housing, which provides a rent subsidy and rapid access to housing of choice in private apartments; a second component is support. Quantitative and qualitative methods were used to evaluate HF implementation. OUTCOMES: The findings of this case study illustrate how the critical ingredients of complex interventions, such as HF, can be adapted to different contexts while implementation fidelity is maintained at a theoretical level. The findings also illustrate how the project's mixed methods approach helped to facilitate the adaptation process. Another value of this approach is that it identifies systemic and organizational factors (e.g., housing supply, discrimination, housing procurement strategy) that affect implementation of key elements of HF. CONCLUSION: In general, the approach provides information about both whether and how key aspects of the intervention are implemented effectively across different settings. It thus provides implementation data that are rigorous, contextually relevant and practical.

The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities.

Introduction Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city, $110 million demonstration project and provides the rationale for key scientific decisions. Methods A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project. Trial registration number This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.

Depressive symptoms as a determinant of breast and cervical cancer screening in women: a population-based study in Ontario, Canada.

The objective of this study was to investigate the relationship between depression and screening for breast and cervical cancer. The study sample included Ontario female respondents to the Canadian Community Health Survey Cycle 1.2, Mental Health and Well Being component (2002). Women with Major Depressive Disorder (MDD) were identified based on the World Mental Health Composite International Diagnostic Interview and women with clinically significant depressive symptoms were identified using the Kessler 6-item Distress Scale (K6 ≥ 8). Respondents eligible for screening (N = 4,042 for cervical cancer and N = 1,403 for breast cancer) were linked to Ontario administrative data to prospectively ascertain screening outcomes. Both women with MDD and K6 ≥ 8 were less likely to receive breast cancer screening than their non-depressed counterparts (46.1% vs. 61.5% for MDD, Χ(2) = 5.47, p = 0.02; 49.9% vs. 61.9% for K6, Χ(2) = 6.61, p = 0.01). Adjusted analyses revealed persistence of the association between K6 ≥ 8 and breast cancer screening (adjusted odds ratio (AOR) 0.63, 95% CI 0.40-0.97). Neither MDD nor K6 ≥ 8 were found to be associated with cervical cancer screening in the full sample. A sub-group analysis by age revealed that women over age 40 years with K6 ≥ 8 were less likely to receive cervical cancer screening than their non-depressed counterparts (49.9% vs. 64.5%, X(2) = 6.47, p = 0.01). This association approached statistical significance in adjusted analysis (AOR = 0.65, 95% CI 0.41-1.04). This study's findings suggest that attention to the uptake of preventive services in women with depressive symptoms is warranted.

A pilot study of an electronic interprofessional evidence-based care planning tool for clients with mental health problems and addictions.

BACKGROUND: The health system must develop effective solutions to the growing challenges it faces with respect to individuals who suffer with mental health disorders and addictions. The purpose of this study was to evaluate the usability and potential impact on outcomes of a knowledge translation system aimed at improving client-centered, evidence-based care for hospitalized individuals with schizophrenia. METHODOLOGY: A pre-posttest design was used. The e-Volution-TREAT system was implemented on two inpatient units at a large mental health facility. Thirty-seven nurses, allied health workers, and physicians participated from two units. Data collection involved questionnaires, semistructured interviews, and observations. Thirty-eight consenting clients' outcome data were collected from organizational records. RESULTS: Overall, staff participants were very satisfied with the functions of the e-Volution-TREAT system. Barriers to using the system were identified by participants related to the work environment, to understaffing, equipment problems, discomfort with technology, and a focus on short-term rather than long-term goals. There was moderate uptake of guidelines related to social issues, and low uptake of guidelines related to family support and addictions. There were significant improvements in four client outcomes over time, specifically aggressive behavior, depression, withdrawal, and psychosis. CONCLUSIONS: In conclusion, users were overall satisfied with the e-Volution-TREAT system, although expressed challenges related to workload that interfered with time to utilize the system. It would be premature to conclude the change in client outcomes was related to the e-Volution-TREAT system without a randomized controlled trial with outcomes compared to a control group. Future research needs to incorporate strategies for modifying the context and engage clinicians who are in a position of influence to model change.

Factor structure of the Multnomah Community Ability Scale--longitudinal analysis.

Community mental health services benefit from measuring clinical outcomes relevant to a community-based context in contrast to medically modeled outcomes. The Multnomah Community Ability Scale (MCAS) addresses broad dimensions of community functioning and was developed for clinical and evaluation purposes. We assessed the structural consistency and fit of the scale as a measure of community functioning through confirmatory factor analysis using a longitudinal sample of individuals (n=408) with severe and persistent mental illness receiving services from community mental health programs. None of the previously hypothesised factor solutions achieved a good fit and a high degree of invariance over time was observed. Through exploratory factor analysis, the possibility of alternative solutions was explored. After exclusion of two of the 17 items, four models--including four-, three-, two- and one-factor solutions--were tested for fit and invariance with no improvement. We discuss our findings of poor fit under the assumption that the MCAS should psychometrically behave as a scale. Alternative interpretations for the tool and suggestions for the use of its items as an index that measures aspects of disability are proposed.

Gender and outpatient mental health service use.

The purpose of this study is to describe gender differences in the use of outpatient mental health services and to identify potential determinants of this use. The study sample, N = 7475 respondents 18-64 years, was drawn from the Mental Health Supplement to the Ontario Health Survey. For theoretical and empirical reasons, type of mental disorder was defined as: a Mood and/or Anxiety Disorder (Mood/Anx) or a Substance Use Disorder and/or Antisocial Behaviours (Subs/Asb) within the past year. Use was defined in relation to providers seen within the past year. Descriptive and multiple logistic regression analyses were employed including type of mental disorder, social and economic factors. Female gender remained positively associated with any use despite adjustments (adjusted OR: 1.7; 95% CI: 1.2: 2.4). The magnitude of this association was consistent across the levels of the study variables and various measures of use except volume of use where there were no gender differences. Mood/Anx appeared to mediate the gender-use relationship and was strongly associated with use (adjusted OR: 8.4; 95% CI: 5.9; 11.9). Subs/Asb was also related to use (adjusted OR: 2.6; 95% CI: 1.5; 4.3) but not to the same degree as Mood/Anx. Mood/Anx explained 60% of the crude Subs/Asb-use relationship. The evidence to suggest that Subs/Asb mediated the gender-use relationship was mixed. These findings raise questions about gender differences in illness and reporting behaviours and the health care system in its preferential treatment of women and those with Mood/Anx.

Exploring the helping relationship between the schizophrenic client and rehabilitation therapist.

This paper argues that the enhanced efficacy of current rehabilitation strategies compared to insight-oriented therapies for schizophrenic clients cannot be understood in terms of differences in technique alone. Rather, the relationship that develops between rehabilitation therapist and schizophrenic client may represent a potent therapeutic ingredient warranting further study. The concept of therapeutic alliance is examined as a means toward understanding the mechanisms underlying successful rehabilitation.