The role of housing stability in predicting social capital: Exploring social support and psychological integration as mediators for individuals with histories of homelessness and vulnerable housing.

Social capital is a collective asset important for individual and population well-being. Individuals who experience homelessness may face barriers in accessing social capital due to health challenges, small social networks, and social exclusion. Data from a 4-year longitudinal study was used to determine if housing stability predicted greater social capital and if this relationship was mediated by social support and psychological integration for a sample of 855 homeless and vulnerably housed participants living in three Canadian cities. Findings showed that housing stability was not associated with trust and linking social capital. However, higher levels of social support and psychological integration had a mediating effect on the association between housing stability and trust and linking social capital. These findings highlight the importance of social support and psychological integration as means of promoting social capital for people who experience homelessness and vulnerable housing. Social interventions for housed individuals with histories of homelessness may be an avenue to foster greater social capital by building relationships with neighbors and connections to community resources and activities.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review.

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

An Examination of the Effectiveness of Smoking Cessation Treatment Interventions for Individuals with Severe Mental Illness: A Pilot Randomized Controlled Trial.

To evaluate the effectiveness of two different smoking cessation interventions for individuals with severe mental illness. Study participants (N = 61) randomly assigned to the SC-R group (n = 29) were offered 24 weeks of no cost Nicotine Replacement Treatment (NRT); participants assigned to the SC + group (n = 32) were offered 24 weeks of no cost NRT plus two initial individual counselling sessions of motivational interviewing and weekly psychosocial group support for 24 weeks. At 6 months the smoking cessation outcome was 7% for the SC-R group and 14% for the SC + group, but there was no statistically significant difference between the groups. Both groups showed a significant decrease in the number of cigarettes smoked per day and significant improvement in physical health functioning. Clients with severe mental illness, high prevalence of co-occurring substance use and experience of homelessness, are both interested and able to quit smoking and reduce cigarette use.

Shelter Bans Among People Experiencing Homelessness: an Exploratory Study of Predictors in Two Large Canadian Datasets.

Emergency shelters are a core component of homeless service systems that address immediate basic needs. Service bans, which refer to temporary or permanent disallowances from a program or organization, are an underresearched phenomenon that can leave people experiencing homelessness without needed supports. This exploratory study examined the factors associated with shelter bans among people experiencing homelessness using secondary data from two Canadian studies: (1) a multisite randomized controlled trial of Housing First (At Home/Chez Soi Demonstration Project) and (2) a cross-sectional survey of youth experiencing homelessness across Canada (2019 Without a Home-National Youth Homelessness Survey). The two datasets were analyzed separately using logistic regression models with similar predictors to maximize the comparability of the results. Participants who experienced homelessness at an earlier age and had recent criminal justice system involvement were more likely to have shelter bans in both datasets. Impaired impulse control, more chronic medical conditions and living in Toronto were associated with increased likelihood of shelter bans in the At Home/Chez Soi dataset, whereas more adverse childhood experiences, physical violence victimization, engagement in survival sex behaviours and longer current episodes of homelessness were significant predictors of bans in the Without A Home dataset. Overall, the findings suggest that victimization and criminalization during homelessness may increase the risk of shelter loss from bans and further exclusion. The observed regional differences also highlight the potential limits of individual-level predictors. Further research is needed on shelter ban outcomes, as well as how capacity limits and organizational policies affect banning decisions.

Multi-trajectory group profiles of well-being and associated predictors among adults experiencing homelessness and mental illness: findings from the At Home/Chez Soi study, Toronto site.

PURPOSE: To conduct a multi-dimensional and time-patterned analysis to identify distinct well-being trajectory profiles over a 6-year follow-up period among adults experiencing homelessness and mental illness. METHODS: Data from 543 participants of the At Home Chez Soi study's Toronto site were examined over a 6-year follow-up period, including measures of quality of life, community functioning, housing stability, and substance use. Well-being trajectories were identified using Group-Based Trajectory Modelling. Multinomial regression was used to identify predictor variables that were associated with each well-being trajectory profile. RESULTS: Four well-being profiles were identified: low well-being, moderate well-being, good well-being, and high well-being. Factors associated with a greater likelihood of following a better well-being profile included receiving Housing First, reporting female gender and non-white ethnicity, having post-secondary studies, and reporting a high resilience level. Concurrently, factors associated with a lower likelihood of better well-being profiles were having a history of chronic homelessness, experiences of discrimination in the healthcare setting, having comorbid mental disorders and a high level of symptom severity, and reporting a history of traumatic brain injury and childhood adversity. CONCLUSIONS: Individuals experiencing homelessness follow distinct well-being profiles associated with their socio-demographic characteristics, health status, trauma history, resilience capabilities, and access to housing and support services. This work can inform integrated housing and support services to enhance the well-being trajectories of individuals experiencing homelessness. TRIAL REGISTRATION: At Home/Chez Soi trial was registered with ISRCTN, ISRCTN42520374, http://www.isrctn.com/ISRCTN42520374 .

A Qualitative Study of the Working Alliance in the Strengths Model of Case Management with People with Severe Mental Illness.

The purpose of this study was to examine clients' perceptions of the client-case manager working alliance in the context of receiving the Strengths Model of Case Management. Twenty people with severe mental illness, with a SMCM case manager, participated in semi-structured, qualitative interviews. Using first and second cycle coding, data were analyzed thematically. People in the study attributed personal life changes to their relationship with their case manager. They valued their case managers' flexibility and highlighted their work on a wide range of goals of their choosing. Case managers approached the SMCM intervention responsive to their clients' preferences and choices. The working alliance serves as a key element of the SMCM intervention. Clients describe the working alliance as helping to improve their lives. This study supports the implementation of SMCM with people with severe mental illness due to its focus on fostering a strong working alliance.

Implementing the Strengths Model of Case Management: Assessing Practice Three Years After Initial Implementation.

While strengths approaches are important to recovery-oriented practice, implementation can be challenging. This study implemented the strengths model of case management (SMCM) in 11 CM teams and assessed the fidelity of delivery and staff perceptions of the model after 36 months using the SMCM fidelity scale and the Readiness Monitoring Tool. Paired sample t-tests assessed change in fidelity from baseline to 36 months. Adjusted regression analyses compared survey responses of direct and management staff. While fidelity ratings significantly improved across all domains, at 36 months they remained suboptimal in supervision practices and use of model tools. Staff perceptions were generally positive but consistently lower for front-line than management staff. Implementing SMCM into existing case management practice with good fidelity is feasible. However, clear support from management may strengthen staff motivation and delivery. A review of practice later in implementation can flag challenges for sustainability and guide implementation support.

Does Housing Improve Health Care Utilization and Costs? A Longitudinal Analysis of Health Administrative Data Linked to a Cohort of Individuals With a History of Homelessness.

BACKGROUND: Individuals who are homeless have complex health care needs, which contribute to the frequent use of health services. In this study, we investigated the relationship between housing and health care utilization among adults with a history of homelessness in Ontario. METHODS: Survey data from a 4-year prospective cohort study were linked with administrative health records in Ontario. Annual rates of health encounters and mean costs were compared across housing categories (homeless, inconsistently housed, housed), which were based on the percentage of time an individual was housed. Generalized estimating equations were applied to estimate the average annual effect of housing status on health care utilization and costs. RESULTS: Over the study period, the proportion of individuals who were housed increased from 37% to 69%. The unadjusted rates of ambulatory care visits, prescription medications, and laboratory tests were highest during person-years spent housed or inconsistently housed and the rate of emergency department visits was lowest during person-years spent housed. Following adjustment, the rate of prescription claims remained higher during person-years spent housed or inconsistently housed compared with the homeless. Rate ratios for other health care encounters were not significant (P>0.05). An interaction between time and housing status was observed for total health care costs; as the percentage of days housed increased, the average costs increased in year 1 and decreased in years 2-4. CONCLUSIONS: These findings highlight the effects of housing on health care encounters and costs over a 4-year study period. The rate of prescription medications was higher during person-years spent housed or inconsistently housed compared with the homeless. The cost analysis suggests that housing may reduce health care costs over time; however, future work is needed to confirm the reason for the reduction in total costs observed in later years.

Overall and Gender-specific Associations between Dimensions of Adverse Childhood Experiences and Mental Health Outcomes among Homeless Adults: Associations Générales et Sexospécifiques Entre les Dimensions des Expériences Défavorables de L'enfance et les Résultats de Santé Mentale Chez les Adultes Sans Abri.

OBJECTIVE: The associations between adverse childhood experiences (ACEs) and psychopathology have been well-established in the general population. Research on ACEs in the homeless population has been limited. This study examined whether ACE exposure is associated with specific mental health outcomes among a national sample of homeless adults with mental illness and whether this association varies according to ACE dimension and gender. METHODS: This cross-sectional study utilized data from a national sample of 2,235 homeless adults with mental illness in Canada to evaluate their sociodemographic characteristics, exposure to ACEs, and mental health outcomes. Exploratory and confirmatory factor analyses were conducted to identify and confirm ACE dimensions (maltreatment, sexual abuse, neglect, divorce, and household dysfunction) from individual ACE items. Multivariable logistic regression was used to examine the associations between total ACE score and ACE dimensions with mental illness diagnoses and psychopathology severity. RESULTS: The mean total ACE score among all study participants was 4.44 (standard deviation [SD]: 2.99). Total ACE score was positively associated with several mental illness diagnoses and psychopathology severity. Unique associations were found between specific ACE dimensions and poor mental health outcomes. The prevalence of almost all ACEs was significantly higher among women. Yet, associations between several ACE dimensions and poor mental health outcomes existed uniquely among men. CONCLUSIONS: There are unique and gender-specific associations between specific ACE dimensions and mental health outcomes among homeless adults. Better understanding of the mechanisms underlying these associations is needed to inform screening, prevention, and treatment efforts, particularly given the very high prevalence of ACEs among this vulnerable and marginalized population.

Factors associated with higher healthcare costs in a cohort of homeless adults with a mental illness and a general cohort of adults with a history of homelessness.

BACKGROUND: Healthcare costs are disproportionately incurred by a relatively small group of people often described as high-cost users. Understanding the factors associated with high-cost use of health services among people experiencing homelessness could help guide service planning. METHODS: Survey data from a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness were linked with administrative healthcare records in Ontario, Canada. Total costs were calculated using a validated costing algorithm and categorized based on population cut points for the top 5%, top 6-10%, top 11-50% and bottom 50% of users in Ontario. Multinomial logistic regression was used to identify the predisposing, enabling, and need factors associated with higher healthcare costs (with bottom 50% as the reference). RESULTS: Sixteen percent of the general homeless cohort and 30% percent of the cohort with a mental illness were in the top 5% of healthcare users in Ontario. Most healthcare costs for the top 5% of users were attributed to emergency department and inpatient service costs, while the costs from other strata were mostly for physician services, hospital outpatient clinics, and medications. The odds of being within the top 5% of users were higher for people who reported female gender, a regular medical doctor, past year acute service use, poor perceived general health and two or more diagnosed chronic conditions, and were lower for Black participants and other racialized groups. Older age was not consistently associated with higher cost use; the odds of being in the top 5% were highest for 35-to-49-year year age group in the cohort with a mental illness and similar for the 35-49 and ≥ 50-year age groups in the general homeless cohort. CONCLUSIONS: This study combines survey and administrative data from two cohorts of homeless adults to describe the distribution of healthcare costs and identify factors associated with higher cost use. These findings can inform the development of targeted interventions to improve healthcare delivery and support for people experiencing homelessness.

[Impact of a journal club on the self-efficacy, expectations, and intentions of nursing students toward evidence-based results]. / Effet d'un club de lecture sur le sentiment d'efficacité personnelle, les attentes et les intentions d'étudiantes en sciences infirmières à l'égard de l'utilisation des résultats probants.

INTRODUCTION: Nursing associations require that nurses develop the skills to integrate evidence into practice to support the quality of care. CONTEXT: Lack of self-confidence in the operational steps of evidence-based practice was identified as a barrier to integrating evidence into nursing practice. OBJECTIVE: To assess the effect of a journal club (JC) on nursing students' self-efficacy (SE), expectations, and intentions to use evidence. METHOD: Quasi-experimental, longitudinal approach with a non-randomized comparison group. RESULTS: The development of SE toward the use of evidence-based practices favored students who participated in the JC (n=48) compared to students who received a conventional educational modality (CEM) (n=50). However, there was no significant group x time interaction effect on expectations or intentions. DISCUSSION: The significant positive changes beyond the CEM may be explained by the fact that the JC incorporated modes of influence on SE. CONCLUSION: The positive effect associated with the JC on SE is difficult to sustain without continued practice. It is important to maintain high outcome expectations within nursing training.

Effet d'un club de lecture sur le sentiment d'efficacité personnelle, les attentes et les intentions d'étudiantes en sciences infirmières à l'égard de l'utilisation des résultats probants.

INTRODUCTION: Nursing associations require that nurses develop the skills to integrate evidence into practice to support the quality of care. CONTEXT: Lack of self-confidence in the operational steps of evidence-based practice was identified as a barrier to integrating evidence into nursing practice. OBJECTIVE: To assess the effect of a journal club (JC) on nursing students' self-efficacy (SE), expectations, and intentions to use evidence. METHOD: Quasi-experimental, longitudinal approach with a non-randomized comparison group. RESULTS: The development of SE toward the use of evidence-based practices favored students who participated in the JC (n=48) compared to students who received a conventional educational modality (CEM) (n=50). However, there was no significant group x time interaction effect on expectations or intentions. DISCUSSION: The significant positive changes beyond the CEM may be explained by the fact that the JC incorporated modes of influence on SE. CONCLUSION: The positive effect associated with the JC on SE is difficult to sustain without continued practice. It is important to maintain high outcome expectations within nursing training.

The Association of Residential Instability and Hospitalizations among Homeless and Vulnerably Housed Individuals: Results from a Prospective Cohort Study.

The present study examined the association of residential instability with hospitalizations among homeless and vulnerably housed individuals over a 4-year time period. Survey data were linked to administrative records on hospitalizations. Specifically, we used data from the Health and Housing in Transition study, a prospective cohort study that tracked the health and housing status of homeless and vulnerably housed individuals in Canada. Responses from Vancouver-based participants (n = 378) from baseline and 3 follow-ups were linked to their administrative health records on hospitalizations (Discharge Abstract Database - Hospital Separation Files; 2008-2012). A generalized estimating equations model was used to examine associations between the number of residential moves and any hospitalizations during each year (none versus ≥ 1 hospitalizations). Analyses included demographic and health variables. Survey data were collected via structured interviews. Hospitalizations were derived from provincial administrative health records. A higher number of residential moves were associated with hospitalization over the study period (adjusted odds ratio: 1.14; 95% confidence interval: 1.01, 1.28). Transgender, female gender, perceived social support, better self-reported mental health, and having ≥ 3 chronic health conditions also predicted having been hospitalized over the study period, whereas high school/higher education was negatively associated with hospitalizations. Our results indicate that residential instability is associated with increased risk of hospitalization, illustrating the importance of addressing housing as a social determinant of health.

Examining the Relationships between Cumulative Childhood Adversity and the Risk of Criminal Justice Involvement and Victimization among Homeless Adults with Mental Illnesses after Receiving Housing First Intervention.

OBJECTIVES: Exposure to adverse childhood experiences (ACEs) is associated with increased risk of criminal justice involvement and repeated victimization among homeless individuals. This study aimed to (1) examine whether the relationship between cumulative ACE score and odds of experiencing criminal justice involvement and victimization remains significant over time after receiving the Housing First (HF) intervention and (2) investigate the moderating effect of cumulative ACE score on the effectiveness of the HF intervention on the likelihood of experiencing these outcomes among homeless individuals with mental illnesses. METHODS: We used longitudinal data over the 2-year follow-up period from the At Home/Chez Soi demonstration project that provided HF versus treatment as usual (TAU) to homeless adults with mental illness in five Canadian cities (N = 1,888). RESULTS: In all 4 follow-up time points, the relationship between cumulative ACE score and both outcomes remained significant, regardless of study arm (HF vs. TAU) and other confounding factors. However, cumulative ACE score did not moderate intervention effects on odds of experiencing either outcome, suggesting that the effectiveness of HF versus TAU, with regard to the odds of being victimized or criminal justice involvement, did not differ by cumulative ACE scores over the course of study. CONCLUSIONS: Findings suggest that providing services for homeless individuals with mental illness should be trauma informed and include specialized treatment strategies targeting the experience of ACEs and trauma to improve their treatment outcomes. An intensive approach is required to directly address the problem of criminal justice involvement and victimization in these individuals.

Indigenous and non-Indigenous parents separated from their children and experiencing homelessness and mental illness in Canada.

The purpose of this study is to examine the parent-child experiences of Indigenous and non-Indigenous mothers and fathers experiencing homelessness, mental illness, and separation from their children. A qualitative thematic analysis of baseline and 18-month follow-up narrative interviews was used to compare 12 mothers (n = 8 Indigenous and n = 4 nonindigenous) with 24 fathers (n = 13 Indigenous and n = 11 non-Indigenous). First, it was found that children are more central in the lives of mothers than fathers. Second, Indigenous parents' narratives were characterized by interpersonal and systemic violence, racism and trauma, and cultural disconnection, but also more cultural healing resources. Third, an intersectional analysis showed that children were peripheral in the lives of non-Indigenous fathers, and most central to the identities of Indigenous mothers. Gender identity, Indigenous, and intersectional theories are used to interpret the findings. Implications for future theory, research, and culturally relevant intervention are discussed.

Effectiveness of Housing First for Homeless Adults with Mental Illness Who Frequently Use Emergency Departments in a Multisite Randomized Controlled Trial.

Frequent emergency department (ED) users experiencing homelessness are associated with high costs for healthcare systems yet interventions for this group have been minimally investigated. This study used 24-month data from a multisite randomized controlled trial of Housing First (HF) to examine how effective the intervention is in helping frequent ED users with a mental illness to achieve housing stability, improve behavioural health and functioning, and reduce their ED use. Findings showed that HF is effective in stably housing frequent ED users despite their complex health needs. Reductions in ED use and substance use problems, and improvements in mental health symptoms and community functioning were found for frequent ED users in both the HF and treatment as usual conditions.

A randomized controlled trial of the effectiveness of Housing First in a small Canadian City.

BACKGROUND: The paper presents two-year findings from a study investigating the effectiveness of Housing First (HF) with assertive community treatment (ACT) in helping individuals with serious mental illness, who are homeless or precariously housed and living in a small city, to become stably housed. METHODS: The research design was a parallel group non-blinded RCT with participants randomly assigned after the baseline interview to receive HF with ACT (N = 100) or treatment as usual (TAU; N = 101). Participants were interviewed every 3 months over 21/24 months to investigate changes on a range of housing and psychosocial outcomes. The primary outcomes were housing stability (as defined by a joint function of number of days housed and number of moves) and improvement in community functioning. Secondary predicted outcomes were improvements in self-rated physical and mental health status, substance use problems, quality of life, community integration, and recovery. RESULTS: An intent-to-treat analysis was conducted. Compared to TAU participants, HF participants who entered housing did so more quickly (23.30 versus 88.25 days, d = 1.02, 95% CI [0.50-1.53], p < 0.001), spent a greater proportion of time stably housed (Z = 5.30, p < 0.001, OR = 3.12, 95% CI [1.96-4.27]), and rated the quality of their housing more positively (Z = 4.59, p < 0.001, d = 0.43, 95% CI [0.25-0.62]). HF participants were also more likely to be housed continually in the final 6 months (i.e., 79.57% vs. 55.47%), χ2 (2, n = 170) = 11.46, p = .003, Cramer's V = 0.26, 95% CI [0.14-0.42]). HF participants showed greater gains in quality of life, (Z = 3.83, p < 0.001, ASMD = 0.50, 95% CI [0.24-0.75]), psychological integration (Z = 12.89, p < 0.001, pooled ASMD = 0.91, 95% CI [0.77-1.05]), and perceived recovery (Z = 2.26, p = 0.03, ASMD = 0.39, 95% CI [0.05-0.74]) than TAU participants. CONCLUSIONS: The study indicates that HF ends homelessness significantly more rapidly than TAU for a majority of individuals with serious mental illness who have a history of homelessness and live in a small city. In addition, compared to TAU, HF produces psychosocial benefits for its recipients that include an enhanced quality of life, a greater sense of belonging in the community, and greater improvements in perceived recovery from mental illness. TRIAL REGISTRATION: International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374 , assigned August 18, 2009.

Predictors of Mental Health Recovery in Homeless Adults with Mental Illness.

For people with mental illness, experiences of homelessness can complicate mental health recovery processes. This study used longitudinal data from a randomized controlled trial of housing first (HF) to examine predictors of recovery among homeless people with mental illness. Findings showed that health and community predictors were most strongly associated with mental health recovery. Receipt of HF did not have any effect on changes in recovery scores at follow-up. Overall, the findings suggest that interventions aimed at preventing chronic homelessness, strengthening social networks and community involvement, and providing case management services will facilitate mental health recovery.

Systems change in the context of an initiative to scale up Housing First in Canada.

In this study, we examine changes in the homeless-serving system in the context of a training and technical assistance initiative to scale up Housing First (HF) in 6 Canadian communities. Based on qualitative data from focus groups and individual interviews with key stakeholders (k = 7, n = 35) and field notes gathered over a 3-year period (n = 146), we found 2 main system changes: (a) changes in the capacity of the service delivery system at multiple levels of analysis (from individual to policy) to implement HF, and (b) changes in the coordination of parts of the service delivery system and collaboration among local stakeholders to enhance HF implementation. These changes were facilitated or constrained by the larger context of evidence, climate, policy, and funding. The findings were discussed in terms of systems change theory and implications for transformative systems change in the mental health and homelessness sectors.

Housing First for older homeless adults with mental illness: a subgroup analysis of the At Home/Chez Soi randomized controlled trial.

OBJECTIVE: This study compares the effect of Housing First on older (≥50 years old) and younger (18-49 years old) homeless adults with mental illness participating in At Home/Chez Soi, a 24-month multisite randomized controlled trial of Housing First. METHOD: At Home/Chez Soi, participants (n = 2148) were randomized to receive rent supplements with intensive case management or assertive community treatment, based on their need level for mental health services, or usual care in their respective communities. A subgroup analysis compared older (n = 470) and younger (n = 1678) homeless participants across baseline characteristics and 24-month outcomes including housing stability (primary outcome), generic and condition-specific quality of life, community functioning, physical and mental health status, mental health symptom severity, psychological community integration, recovery, and substance use (secondary outcomes). RESULTS: At 24 months, Housing First significantly improved the percentage of days stably housed among older (+43.9%, 95% confidence interval [CI]: 38.4% to 49.5%) and younger homeless adults (+39.7%, 95% CI: 36.8% to 42.6%), compared with usual care, with no significant differences between age groups (difference of differences = +4.2%, 95% CI: -2.1% to 10.5%, p = 0.188). Improvements from baseline to 24 months in mental health and condition-specific quality of life were significantly greater among older homeless adults than among younger homeless adults. CONCLUSION: Housing First significantly improved housing stability among older and younger homeless adults with mental illness, resulting in superior mental health and quality of life outcomes in older homeless adults compared with younger homeless adults at 24 months. Copyright © 2017 John Wiley & Sons, Ltd.