Linking Health and Housing Data to Create a Sustainable Cross-Sector Partnership.

In response to the growing regional (and national) focus on health and housing intersections, two public housing authorities (PHAs) in Washington-the King County Housing Authority and the Seattle Housing Authority-joined with Public Health-Seattle & King County to form the Housing and Health (H&H) partnership in 2016. H&H linked Medicaid health claims with PHA administrative data to create a sustainable public-facing dashboard that informs health and housing stakeholders such as an Accountable Community of Health (a governing body that oversees local Medicaid transformation projects), managed care organizations, and PHAs, allowing insights into the low-income communities they serve.

Scaling Up Housing Services Within the Child Welfare System: Policy Insights From Simulation Modeling.

OBJECTIVES: Housing insecurity and homelessness contribute to risk of maltreatment among one in five of the nearly 3.5 million children annually investigated for maltreatment in the United States. The Family Unification Program (FUP)-a federal initiative-connects inadequately housed families involved in child welfare with long-term rental subsidies to avoid foster placement. However, FUP remains understudied and underutilized with funding levels that serve only a fraction of eligible households. The present study uses system dynamics modeling to inform decision-making by testing policies for scaling FUP. METHOD: Simulations model delivery of FUP within child welfare from a feedback perspective. Calibrated on national data, models replicate trends in child welfare involvement from 2013 through 2016, and analyses forecast rates through 2019. Experiments test policies that enhance FUP. Outcomes track system-wide rates of family separation and returns on investment of expanded housing interventions. RESULTS: Dramatic expansions of FUP benefit more families and improve marginal return on investment. Yet, scale-up fails to reduce system-wide rates of family separation or generates substantial cost-savings. CONCLUSIONS: Simulations demonstrate structural challenges for scaling FUP. Constant demand for affordable housing constrains sustainable improvements in child protection. Child welfare responses to homelessness require innovations that reduce demand for housing services through prevention and earlier intervention.

Comparing Tenant and Neighborhood Characteristics of the VA's Project- vs. Tenant-Based Supportive Housing Program in Los Angeles County.

The United States Department of Housing and Urban Development (HUD)-Veteran Administration Supportive Housing (VASH) program uses project- and tenant-based vouchers to provide permanent supportive housing for homeless Veterans. We compared Veteran characteristics, health service utilization, and neighborhood characteristics between HUD-VASH participants with project-based (n=114) vs. tenant-based (n=978) vouchers. We found that project-based voucher holders were older and more ill than tenant-based voucher holders. Project-based vouchers were also associated with higher-quality neighborhoods and higher rates of health service utilization than tenant-based vouchers. With the limited availability of project-based vouchers, juxtaposed with the increased service use and better neighborhood quality with this voucher type, our findings suggest a need to think strategically about how best to allocate housing vouchers to meet homeless Veteran's needs.

Development of an Interprofessional Home Healthcare Management Service: Within an Urban Housing Development.

In response to the need for increased access to primary care services for a low-income, at-risk community, two local universities partnered with a nonprofit Housing and Urban Development affiliated provider of affordable housing to launch a primary care clinic within an urban public housing community. Although the establishment of this clinic represented progress in meeting many healthcare needs of the target population, an interprofessional team also identified a need for the initiation of a new home-based service line. The goal of this project was to establish an innovative, sustainable, and cost-effective healthcare delivery method that would improve the health of this population. The project focused on a literature review, needs-assessment, and development of a comprehensive medical home visit program to serve the homebound, frail elderly, and other at-risk adults with complex medical conditions who reside in this community. The medical needs of potential recipients were assessed by conducting interviews with key support staff including a health service coordinator, health advocates, and housing provider service coordinators. Residents were also interviewed using a newly developed health perception and information survey. The data derived from the needs-assessment and pertinent literature were used to draft an initial program guideline. Because the needs-assessment indicated this population would not derive maximum benefit from a traditional house calls program, the project team developed a Home Healthcare Management service with an expanded scope to provide enhanced care coordination, house visits (medical and nonmedical), and community outreach.

Youth homelessness and housing stability: What outcomes should we be looking for?

In North America, the key performance indicator of success in community strategies to address homelessness is whether a homeless person is housed or not. In this article, we argue that for young people experiencing homelessness, we need to advance a broader consideration of outcomes to include a range of well-being indicators designed to understand the needs of developing adolescents and young adults and contribute to housing stability. We articulate that the positive outcomes of young people across life domains that include housing stability as well as their safety and security, health and well-being, social connections to peers, family and meaningful adults, connections to groups/neighbourhoods/communities, interests and recreation and leisure, and school and career/work aspirations and goals must be at the centre of these efforts. The Making the Shift project is designed to test this outcomes framework in order to enhance service and measurement capacity and ultimately improve outcomes for youth.

Are resilience and perceived stress related to social support and housing stability among homeless adults with mental illness?

Perceived stress has been associated with adverse health outcomes. Although people experiencing homelessness often report multiple acute and chronic stressors, research on resilience and perceived stress on the general homeless population is limited. This longitudinal study examined homeless adults with mental illness who were part of a 24-month trial of Housing First to explore: (a) changes in levels of resilience and perceived stress during the trial, and (b) the association between levels of resilience and perceived stress with measures of social support, social functioning and percentage of days stably housed over the study period. This longitudinal study (2009-2013) that used trial data included 575 participants in Toronto, Ontario. Of these individuals, 507 were included in this study. Connor-Davidson Resilience Scale and Perceived Stress Scales (PSS) measured the two outcomes, resilience and perceived stress. Time (baseline, 12 and 24 months), housing stability and three measures of social support and social functioning were the main predictors. A longitudinal analysis was done with repeated measures analysis of resilience and perceived stress using linear mixed models with random intercepts. Mean resilience scores increased (baseline: 5.1 [95% CI: 4.9, 5.2], 12 months: 5.5 [95% CI: 5.3, 5.7], 24 months: 5.6 [95% CI: 5.4, 5.8]), and PSS scores decreased (baseline: 22.3 [95% CI: 21.5, 23.0], 24 months: 18.6 [95% CI: 17.9, 19.4]). In the multivariable analyses, increased resilience was associated with higher scores on the three social support and social functioning measures, (estimates = 0.12, 0.04, 0.02) but not percentage days stably housed. Lower PSS scores were associated with higher scores on all three social support and social functioning measures (-0.20, -0.33, -0.21) and higher percentages of days stably housed (-0.015). Strong social support and social functioning may minimise the harmful effects of stressful life events on homeless individuals by increasing resilience and reducing stress. Interventions to help homeless people build appropriate support networks should be delivered in parallel to efforts that increase housing stability.

Sowing social inclusion for marginalised residents of a social housing development through a community garden.

ISSUE ADDRESSED: In addition to food, physical activity, mental health and environmental benefits, community gardens (CGs) provide opportunities for social inclusion and increased social capital. These are particularly important to the socially isolated residents of social housing developments (SHDs). This scoping study explored the feasibility of a CG program for tenants of SHD in inner eastern Melbourne by assessing their interest in, and requirements for, inclusively designed CGs. METHODS: In this phenomenological enquiry, focus group discussions, supported by photo-elicitation, were employed. Three focus groups (N = 19) were conducted with self-selected participants who consented to participate. Two focus groups were conducted with English-speaking tenants while a third focus group was conducted with Mandarin-speaking tenants. RESULTS: There was a demand for CGs by the English-speaking participants driven by desire for networking, social connectedness and inclusion; for improved access to fresh produce, connection with nature, physical activity and mental well-being. Participants expressed interest in a garden located near their SHD with supportive physical and social environments including disability access, plot autonomy, fencing, socio-cultural events, training programs and management opportunities. However, the Mandarin-speaking tenants maintained that age, language difficulty and neighbourhood insecurity posed significant barriers to their participation. CONCLUSION: Guided by the Ottawa Charter for Health Promotion, social inclusion and community development theories, the study recommends that to establish socially inclusive CGs, a dynamic relationship of the design principles of a CG and the socio-ecological determinants of health should be established to address any barriers and successfully facilitate engagement. In addition, CG programs need to be guided by community development principles. Future research could employ community-based participatory research models in the implementation and evaluation of a CG program for socially isolated population groups.

Characteristics of Mothers and Infants Living in Homeless Shelters and Public Housing in New York City.

Introduction Homelessness can result in poor health. The number of families with children living in NYC homeless shelters increased 55% from 2008 to 2014. Half of children living in shelter in 2014 were younger than 6 years old. We compared demographics and health outcomes of mothers and infants residing in NYC homeless shelters to those residing in public housing in this cross-sectional study. Methods Addresses of NYC Department of Homeless Services shelters and NYC Housing Authority (NYCHA) developments were matched to NYC Department of Health birth certificate data for the years 2008-2013. Sociodemographic and health characteristics of newborns residing in shelters were compared to newborns in NYCHA housing using Chi square tests. Results Mothers residing in shelters were younger, more likely to be black and less likely to be Hispanic, more likely to have been born outside NYC and reside in the Bronx. Babies born to mothers living in shelter were more likely to have low birth weight (< 2500 g), be born preterm (< 37 gestational weeks), require assisted ventilation immediately following delivery, have a NICU admission, and use Medicaid. They were less likely to breastfeed within 5 days of delivery and be discharged to their residence. Discussion Homeless mothers and infants had poorer health outcomes compared with those living in public housing. Understanding the health disparities of homeless infants can provide guidance for developing future policies and research initiatives, which may be used to inform the development of new policies to improve health outcomes of homeless infants and their mothers.

Permanent Housing Placement and Reentry to Services Among Family Recipients of Homelessness Prevention and Rapid Re-Housing Program (HPRP) Assistance.

The Homelessness Prevention and Rapid Re-Housing Program (HPRP) provided individuals and families who were either at-risk or currently experiencing homelessness with time-limited financial and housing support services. Evaluations of HPRP showed a high rate of family placement into permanent housing. However, little research has explored immediate and longitudinal outcomes for families enrolled in HPRP. Using Homeless Management Information System data from Indianapolis, Indiana, we examined demographic and program-related predictors of families entering permanent housing and their risk of reentry into homeless services following HPRP participation. The sample included 511 families who enrolled in the program from 2009 to 2012, with an average follow-up period of 4.5 years. We conducted analyses separately for Homelessness Prevention (HP) recipients (n = 357) and Rapid Re-Housing (RRH) recipients (n = 154). Results revealed that HP families were more likely to enter permanent housing if they: included adults who were older in age, were enrolled longer in the program, were provided rental arrear services and utility payments, and did not receive legal services. RRH families receiving rental assistance services had significantly greater odds of entering permanent housing. Among permanently housed families, at least one family member in 10.9% of HP recipients and 18.8% of RRH recipients reentered homeless services. HP families with younger children and one veteran family member were at increased risk of reentry to homelessness services. RRH recipients who did not receive moving cost services and had more children were at greater risk of reentry. Study findings suggest a need for future research on HP and RRH interventions that identify unique service needs among families who are experiencing housing instability or homelessness.

Supported housing for persons with serious mental illness and personal recovery: What do families think?

BACKGROUND AND AIMS: Previous research on supported housing for people with serious mental illness focuses primarily on tenant/client experiences. The aim of this article is to present families' perspectives on the role of supported housing in recovery, utilizing the CHIME framework of personal recovery. METHOD: Qualitative interviews were conducted with 14 families of individuals with serious mental illness living in supported housing. Participants were across five supported housing sites in four Canadian provinces. RESULTS: Families credited supported housing with helping tenants redefine a positive sense of identity, re-establish social relationships and regain control over their lives. Families were less confident about supported housing facilitating future employment or 'full' recovery, focusing on stability rather than continual improvement. CONCLUSION: This is one of the first studies to report family perspectives on the role of supported housing in their loved one's recovery processes - both strengths and weaknesses.

Can Public Housing Decrease Segregation? Lessons and Challenges From Non-European Immigration in France : Can Public Housing Decrease Segregation?

Recent decades have seen a rapid increase in the share of non-European immigrants in public housing in Europe, which has led to concern regarding the rise of ghettos in large cities. Using French census data over three decades, we examine how this increase in public housing participation has affected segregation. While segregation levels have increased moderately, on average, the number of immigrant enclaves has grown. The growth of enclaves is being driven by the large increase in non-European immigrants in the census tracts where the largest housing projects are located, both in the housing projects and the surrounding nonpublic dwellings. As a result, contemporary differences in segregation levels across metropolitan areas are being shaped by the concentration of public housing within cities, in particular the share of non-European immigrants in large housing projects constructed before the 1980s. Nevertheless, the overall effect of public housing on segregation has been ambiguous. While large projects have increased segregation, the inflows of non-European immigrants into small projects have brought many immigrants into census tracts where they have previously been rare and, thus, diminished segregation levels.

Place and community inclusion: Locational patterns of supportive housing for people with intellectual disability and people with psychiatric disorders.

PURPOSE: This study examines the locational patterns of publicly-funded supportive housing for people with intellectual disability (people with ID) and people with psychiatric disorders (people with PD). METHODS: Administrative data provided housing locations of 4599 people with ID and people with PD in one urban county and one suburban county in the United States. Census tract data captured neighborhood characteristics. Descriptive statistics and spatial analysis were used to analyze the distribution of supportive housing sites. RESULTS: People with ID were more dispersed across a larger number of census tracts with smaller number of residents per tract than people with PD. While spatial dispersion in favor of people with ID was consistent across both counties, difference in dispersion was more pronounced in the urban county. People with PD were concentrated in neighborhoods with more socio-economic disadvantage, more residential instability, and a higher level of race/ethnic diversity than people with ID. CONCLUSION: This study suggests that spatial-analytic method can serve as a useful tool for assessing the extent to which integrated housing is achieved for people with ID and people with PD. Interpretation of findings should be given due consideration of the policy context and neighborhood characteristics of the study communities.

Nontraditional Alcohol and Opioid Agonist Treatment Interventions.

Despite the availability of effective medications and psychosocial interventions for the management of a substance use disorder, some individuals repeatedly fail the most aggressive treatment regimens. For such individuals, alternative treatment options exist seeking to mitigate the negative consequences of the use of harmful substances. Participation in a managed alcohol program, or the use of sustained-release oral morphine or injectable opioid agonist treatment or the creation of safe injecting facilities, are examples of such nonstandard approaches. This article reviews the available evidence of these treatment modalities.

Access to Affordable Housing Promotes Health and Well-Being and Reduces Hospital Visits.

Clinical interventions can only partially mitigate homelessness and housing insecurity, which are threats to health and well-being. Clinicians have several opportunities to address these problems: They can refer patients who are homeless or housing insecure to support services, advocate for their employer or care group to commit resources to end homelessness and housing insecurity, and/or work with government and private sector community organizations to address and eliminate these problems. Citing examples from around the US, we will illustrate how clinics, hospitals, health plans, and public health organizations work to engage in initiatives to end homelessness and housing insecurity.

Supported housing for adults with psychiatric disabilities: How tenants confront the problem of loneliness.

The objective of this study was to examine the experience of loneliness among people with psychiatric disabilities after moving from custodial housing, including group homes, boarding homes, and family-type residences to independent, supported apartments in the community. Qualitative research methods guided by a naturalistic/constructivist framework were used. Data collection occurred between May 2014 and July 2015 and consisted of individual semi-structured interviews with 24 tenants residing in five supported housing sites across three Canadian provinces; interviews were also conducted with a designated family member for each tenant and with their service providers. Group interviews were conducted with housing workers in the five housing sites. The interviews were transcribed verbatim, codes generated and a thematic analysis undertaken using a constructivist approach. Results showed that for most tenants living in independent apartments with support loneliness was not a serious problem or was an issue that could be overcome. Most study participants viewed supported housing as preferable to custodial housing and as a normalising experience that facilitated community integration. While housing conditions, particularly those associated with congregate housing, sometimes helped attenuate loneliness among tenants, managing loneliness was primarily contingent on the ability of individuals to develop and maintain social connections, as well as on family involvement.

Supportive housing for chronically homeless individuals: Challenges and opportunities for providers in Chicago, USA.

Chronically homeless individuals often have extensive health, mental health and psychosocial needs that pose barriers to obtaining and maintain supportive housing. This study aims to qualitatively explore supportive housing providers' experiences and challenges with housing chronically homeless individuals and examine opportunities to improve supportive housing systems of care. In 2014, we conducted qualitative in-depth interviews with 65 programme administrators and case managers of supportive housing programmes in Chicago, IL. Data were analysed using an inductive thematic content analysis. Analysis revealed four themes that capture the primary challenges faced by housing providers: housing priorities, funding cuts, co-ordinated entry and permanency of housing. Housing for the chronically homeless has been prioritised, yet service providers are being expected to provide the necessary services to meet the needs of this population without commensurate funding increases or agency capacity. Additionally, case managers and administrators discussed the tension over housing tenure and the permanency of supportive housing. Findings provide qualitative insight into the challenges providers face implementing supportive housing for chronically homeless individuals.

Emergent leadership among tenants with psychiatric disabilities living in supported housing.

The overall aim of this study was to explore the experiences of people with psychiatric disabilities living as tenants in independent, supported apartments for the first time. Supported housing provides an alternative to structured, custodial housing models, such as foster homes, or board-and-care homes, for clients in public mental health systems. This article reports findings on how leadership emerged among tenants after making the transition from custodial to supported housing. Semi-structured interviews were conducted with tenants (n = 24) and included questions on their housing history, current living situation, relationships with staff, participation, and understanding or experience of leadership. Interviews were transcribed verbatim, codes generated, and a thematic analysis conducted using a constructivist approach. The findings revealed an understanding and appreciation of leadership among tenants, who identified six pathways to leadership in their housing as a response to unmet tenant needs. Most tenant leaders emerged outside of formal authority or power structures. Supported housing provides a unique social setting and empowering community where the potential of persons with psychiatric disabilities to assume leadership may be realized and further developed. Mental health professionals working in community housing networks are well placed to harness these face-to-face tenant communities, and their natural leaders, as an additional tool in promoting tenant recovery, mutual help, neighbourhood integration, and the broader exercise of citizenship.

Sustaining Housing First After a Successful Research Demonstration Trial: Lessons Learned in a Large Urban Center.

OBJECTIVES: This study aimed to identify challenges and facilitators of sustaining a Housing First intervention at the conclusion of a research demonstration project in Toronto. METHODS: This qualitative study included key informant interviews with organizational leaders (N=13) and focus groups with service team members (N=14) and program participants (N=9) of the At Home/Chez Soi Research Demonstration Project. Thematic analysis was used to identify key themes related to sustainability of Housing First beyond the demonstration phase. RESULTS: Factors that helped secure long-term funding support for Housing First included the positive findings of a rigorous evaluation, early stakeholder engagement, and strong local leadership. Reduced funding, poor intersectoral integration, and lack of central oversight threatened fidelity to the evidence-based model and challenged sustainability. CONCLUSIONS: Evidence-based complex interventions such as Housing First require robust intersectoral collaboration and flexible systems for funding and monitoring to ensure continuing model fidelity and responsiveness to changing contexts.

State strategies for coordinating Medicaid and housing services.

OBJECTIVE: This article reports findings from case studies of 4 states (Illinois, Louisiana, Massachusetts, and Tennessee) that used different approaches to coordinate Medicaid services with temporary or permanent housing supports for individuals with psychiatric disabilities. METHOD: Data were collected through document review, telephone interviews with state officials and managed care organizations, and site visits to behavioral health and housing providers, and consumer organizations. Qualitative analyses focused on identifying key features of each state's approach, including the strengths and limitations from multiple perspectives. RESULTS: All 4 states facilitated partnerships between behavioral health and housing providers. Each state used managed care strategies to some degree and identified opportunities to use Medicaid to finance the coordination of services with housing providers. These financing strategies included using flexible case rates to fund community support workers; using a 1915(i) state plan amendment to fund intensive Medicaid behavioral health services for those in permanent supportive housing; funding new local entities to support local partnerships between health and housing organizations; and creating a Medicaid supportive housing benefit. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These 4 states took advantage of the flexibility that Medicaid offers to implement different service models in an effort to improve the coordination of behavioral health services and housing. The strategies used in these states may be useful to other states and communities seeking to strengthen coordination of care for individuals who require housing support. (PsycINFO Database Record