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.

Workplace trauma and chronic stressor exposure among direct service providers working with people experiencing homelessness.

BACKGROUND: Service providers working with people experiencing homelessness can be directly and indirectly exposed to trauma and other chronic stressors in their work. The types of individuals that are most at-risk of problematic outcomes from traumatic event exposure are unknown. AIM: This study examined exposure to and effects of workplace traumas and stressors among service providers working with people experiencing homelessness in Canada. METHODS: A cross-sectional survey was completed by 701 direct service providers working in the homeless service, supportive housing, and harm reduction sectors. Descriptive statistics, hierarchical multiple regression, and double moderation models were used in the analysis. RESULTS: Employment in homeless service settings, service provision to single adults, and more time in direct contact with service users were each positively associated with the frequency of exposure to critical events and chronic stressors. Younger age, lived experience of behavioural health problems, more frequent exposure to chronic stressors, and less social support from coworkers were significantly correlated with post-traumatic stress and general psychological distress. Emotional support from supervision moderated the relationship between direct exposure to workplace critical events and post-traumatic stress. CONCLUSIONS: More trauma-informed psychosocial supports tailored to the needs of direct service providers working with people experiencing homelessness are needed.

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.

Mental Health and Wellness of Service Providers Working with People Experiencing Homelessness in Canada: A National Survey from the Second Wave of the COVID-19 Pandemic.

OBJECTIVE: This study examined the scope of common mental health problems and perceived impacts of the COVID-19 pandemic among direct service providers working with people experiencing homelessness in Canada. METHOD: This cross-sectional study used an online survey that was disseminated to homeless service, supportive housing, and harm reduction organizations and networks. Data were collected on depression, anxiety, stress, post-traumatic stress, compassion satisfaction and fatigue, and substance use problems as well as pandemic-related changes in mental health and wellness. A total of 701 service providers completed the survey and were included in data analysis. Descriptive statistics were used to examine the primary research questions, with hierarchical multiple regression models also being fit to explore mental health and wellness differences by occupational service setting. RESULTS: Most direct service providers (79.5%) working with people experiencing homelessness reported a decline in their mental health during the pandemic. There were high rates of common mental health problems within the sample that are largely consistent with those found among health-care workers during the pandemic. Occupational service settings were not associated with the severity of mental health problems, indicating pervasive issues across the workforce, though providers who were younger and spent more time in direct service roles were at greater risk. CONCLUSIONS: The common mental health problems and negative impacts of the pandemic among service providers working with people experiencing homelessness highlight a highly vulnerable workforce that could benefit from improved access to supports. Given the similarities between our findings and other studies examining essential workforces, it is recommended that initiatives that provide accessible mental health care to the health-care workforce during the pandemic be expanded to include homeless and social service providers.

Cycles of instability: Proximal and distal influences on residential instability among people with histories of homelessness in three Canadian cities.

People with histories of homelessness often have difficulties obtaining and maintaining adequate housing. This qualitative study examined the residential transitions of people with histories of residential instability and homelessness to understand factors contributing to the instability they experience. Interviews were conducted with 64 participants about their housing transitions, in the final year of a 4-year, prospective cohort study in three Canadian cities (Ottawa, Toronto, and Vancouver). Findings showed that participants pointed to both distal and proximal factors as affecting residential transitions, including interpersonal conflict, safety concerns, substance use, poverty, pests, and health. Many reported disconnection from their housing and a lack of improvement from one housing situation to the next, demonstrating how even when housed, instability persisted. Our study highlights the complexity associated with participants' often unplanned and abrupt residential transitions. The complex and distal issues that affect housing transitions require structural changes, in addition to individual-based interventions focused on the proximal problems.

Finding home: Community integration experiences of formerly homeless women with problematic substance use in Housing First.

AIMS: This study explored community integration among women participating in a Housing First program. Physical, social, and psychological dimensions of community integration were examined. METHODS: This study used neighborhood walk-along and photo-elicitation interviews to explore 16 formerly homeless women's experiences of community integration. RESULTS: Participants described limited community integration. Health, poverty, service inaccessibility, and safety concerns shaped how they took part in activities in their neighborhoods. Participants primarily socialized with people in their buildings, though some preferred to keep to themselves. There was minimal sense of neighborhood belonging, with participants not interested in belonging to a community and being judged by others. CONCLUSION: Housing First promoted housing stability but did not contribute to community integration. Participants did not express a strong desire to integrate in their communities. Future research should consider the extent to which community integration remains a priority for marginalized populations, such as formerly homeless women.

The Healthcare Triple Aim in the Recovery Era.

Recovery is the guiding vision of mental health systems and policy. However, skepticism has emerged about whether the paradigm can achieve its sought goals. We argue that embedding recovery within a quality improvement framework, such as the Triple Aim, would increase leverage for systems change and advance recovery practice. The Triple Aim's goals of improving healthcare outcomes, quality, and costs are pertinent to mental health systems, although action is also needed to address the social determinants of health. Accordingly, we propose the recovery-oriented Triple Aim, which could be used to guide policy development and evaluation of mental health services.

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.

Perceptions of Service Use Among Currently and Formerly Homeless Adults with Mental Health Problems.

This qualitative study used in-depth interviews to examine the service experiences of 52 currently and formerly homeless people with mental health problems. Thematic analysis identified five themes associated with positive and negative service experiences: (1) accessibility of services, (2) humanity in approach to care, (3) perceptions and relationships with other service users, (4) physical space and environment, and (5) outcomes of service use. Overall, minimal differences were found between currently and formerly homeless people with mental health problems, suggesting that both groups have the same wants and needs related to service use, including to be treated fairly and without judgment, receive needed support and assistance, and feel good following their service experience. However, both groups also described encountering barriers to accessing programs and navigating service systems; using services where they felt judged, unsafe, or uncared for; and having unmet needs following service use.

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.

The effects of housing stability on service use among homeless adults with mental illness in a randomized controlled trial of housing first.

BACKGROUND: Housing First is an effective intervention to stably house and alter service use patterns in a large proportion of homeless people with mental illness. However, it is unknown whether there are differences in the patterns of service use over time among those who do or do not become stably housed and what effect, if any, Housing First has on these differing service use patterns. This study explored changes in the service use of people with mental illness who received Housing First compared to standard care, and how patterns of use differed among people who did and did not become stably housed. METHODS: The study design was a multi-site randomized controlled trial of Housing First, a supported housing intervention. 2039 participants (Housing First: n = 1131; standard care: n = 908) were included in this study. Outcome variables include nine types of self-reported service use over 24 months. Linear mixed models examined what effects the intervention and housing stability had on service use. RESULTS: Participants who achieved housing stability, across the two groups, had decreased use of inpatient psychiatric hospitals and increased use of food banks. Within the Housing First group, unstably housed participants spent more time in prison over the study period. The Housing First and standard care groups both had decreased use of emergency departments and homeless shelters. CONCLUSIONS: The temporal service use changes that occurred as homeless people with mental illness became stably housed are similar for those receiving Housing First or standard care, with the exception of time in prison. Service use patterns, particularly with regard to psychiatric hospitalizations and time in prison, may signify persons who are at-risk of recurrent homelessness. Housing support teams should be alert to the impacts of stay-based services, such as hospitalizations and incarcerations, on housing stability and offer an increased level of support to tenants during critical periods, such as discharges. TRIAL REGISTRATION: ISRCTN. ISRCTN42520374 . Registered 18 August 2009.

Poverty and Serious Mental Illness: Toward Action on a Seemingly Intractable Problem.

This paper examines the issue of poverty among people with serious mental illness (SMI), positioning it as a key issue to be confronted by community mental health systems and practitioners. The paper reviews three perspectives on poverty, considering how each sheds light on poverty among people with SMI, and their implications for action: (a) monetary resources, (b) basic needs, and (c) capabilities. The paper argues that community mental health programs and systems are currently unable to address poverty as they are overly focused on individual-level interventions that, on their own, cannot raise people out of poverty. The paper calls for a social justice value, informed by the concept of citizenship, as a necessary complement to the recovery concept that has informed community mental health practice for almost 25 years. Finally, the paper argues that community psychologists, with their concepts, methods, and values, are well positioned to contribute to this important issue. However, it also contends that addressing poverty requires collaboration from community psychologists with researchers and practitioners from other fields and domains of expertise to begin to make progress.

Antecedents and Consequences of Violence in Homeless Shelters: Perspectives and Experiences of Service Users and Shelter Staff.

Violence is a critical issue in homeless shelters that affects service users and staff, yet there is limited evidence on how shelter-based violence occurs. The objective of this qualitative study was to investigate the antecedents and consequences of shelter-based violence from the perspectives of service users and staff. Purposive sampling was used to recruit individuals experiencing homelessness and shelter staff in a large metropolitan city in Ontario, Canada. Data from in-depth interviews with 56 individuals experiencing homelessness and 30 shelter staff were analyzed. Findings showed that shelter-based violence toward service users and staff was perceived to manifest in response to three interacting factors: (a) burden of homelessness and shelter living, (b) individual histories and marginalization, and (c) interpersonal conflict. These antecedents had a hierarchical structure in that each subsequent factor exacerbated the risk of previous ones and culminated with the most proximal factor for violence. There were three primary outcomes of shelter-based violence reported by service users and staff: (a) health and environmental harms, (b), procedural enforcement, and (c) avoidant behaviors. Avoidance was often a subsequent impact following health harms, as was procedural enforcement to a lesser extent. Overall, the study findings demonstrate that shelter-based violence is a complex and dynamic problem that is perceived to be the result of interacting structural, environmental, programmatic, interpersonal, and individual factors, with similar consequences for service users and staff. Implications for preventing violence through shelter design and service delivery are discussed.

Service restrictions from emergency shelters among people experiencing homelessness: Uncovering pathways into unsheltered homelessness and institutional circuitry.

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada. A total of 49 people experiencing homelessness who had been restricted from an emergency shelter program in the past year were recruited and included in the study analysis. A pragmatic and integrative approach was used for data analysis that involved the development of meta-matrices to identify prominent and divergent perspectives and experiences with regard to service restriction antecedents and consequences. Study findings underscored that service restrictions were often the result of violence and aggression, primarily between service users. There were regional differences in other service restriction reasons, including substance use and possession. Service restrictions affected the shelter status of almost all participants, with many subsequently experiencing unsheltered homelessness, and cycling through institutional health, social, and criminal justice services (i.e., institutional circuitry). Other health and social consequences included substance use relapses and hospitalizations; cold-related injuries due to post-restriction unsheltered homelessness; suicidality; food insecurity; diminished contact with support network and connections; and intense feelings of anger, fear, and hopelessness. Overall, the study findings advance our understanding of the role of homeless services in pathways into unsheltered homelessness and institutional circuitry, which raise critical questions about how to mitigate the harms associated with service restrictions, while concurrently facilitating safety and upholding the rights of people experiencing homelessness and emergency shelter staff.

A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness.

OBJECTIVE: Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto. METHODS: The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest. RESULTS: No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period. CONCLUSIONS: In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.

Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis.

The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters. Service users' perceptions of shelter dangerousness were shaped by the service model and environment, interpersonal relationships and interactions in shelter, availability of drugs, and previous living arrangements. 2SLGBTQ+ individuals were identified as being at heightened risk of victimization in shelters. No studies examined rates of shelter-based victimization or tested interventions to improve safety, with the exception of overdose risk. These knowledge gaps hinder the establishment of evidence-based practices for promoting safety and preventing violence in shelter settings.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada.

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services. Thirty participants were recruited via posters placed throughout the building and semi-structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma-free care. Close proximity and convenience of drop-in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre-existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low-barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.

Gains and losses within the homeless service, supportive housing, and harm reduction sectors during the COVID-19 pandemic: A qualitative study of what matters to the workforce.

The COVID-19 pandemic has had deleterious effects on individuals experiencing homelessness; yet, less is known about how this global health crisis is impacting service providers that support the homeless population. This qualitative study examined the perceived impacts of the COVID-19 pandemic on the lives and work experiences of service providers in the homeless service, supportive housing, and harm reduction sectors in Canada. Further analyses were conducted to identify the occupational values that were represented in the work-related changes experienced by providers. A stratified purposive sample of 40 participants (30 direct service providers and 10 providers in leadership roles) were drawn from a pan-Canadian study of the mental health of service providers working with individuals experiencing homelessness. Reflexive thematic analysis was used to identify five themes of the work-related changes experienced by service providers during the pandemic: [1] "Everything was changing every day": Work role and responsibility instability; [2] "How on Earth do we do our job?": Challenges to working relationships with service users; [3] "It used to be a social environment": Transitions to impersonal and isolating workspaces; [4] "It all comes down the chute": Lack of organisational support and hierarchical conflict; and [5] "We've been supported as well as we could have": Positive organisational support and communication. The findings underscored how many of the occupational changes during the pandemic did not align with service providers' occupational values for collaboration, control, effective and safe service provision, and the importance of human relationships, among other values. As pre-existing sectoral problems were exacerbated by the pandemic, recovery efforts need to address these long-standing issues in ways that are aligned with service providers' values. Future research is warranted on how organisational approaches can promote supportive workplaces for service providers and improve outcomes for individuals experiencing homelessness.

Towards the Quadruple Aim in permanent supportive housing: A mixed methods study of workplace mental health among service providers.

The Quadruple Aim is a health policy framework with the objective of concurrently improving population health, enhancing the service experience, reducing costs and improving the work-life of service providers. Permanent supportive housing (PSH) is a best practice approach for stably housing people experiencing homelessness who have diverse support needs. Despite the intervention's strong evidence base, little is known about the work-life of PSH providers. This study explored the mental health and work challenges experienced by PSH providers in Canada. Using an explanatory sequential, equally weighted, mixed methods design, 130 PSH providers were surveyed, followed by semi-structured interviews with 18 providers. Quantitative findings showed that 23.1% of PSH providers had high psychological distress. Participants who were younger, spent all or almost all of their time in direct contact with service users and had less social support from coworkers were significantly more likely to have high psychological distress. Three themes were identified from the qualitative analysis that showed how PSH providers experience psychological distress from work-related challenges: (a) Sisyphean Endeavours: 'You Do What You Can', (b) Occupationally Unsupported: 'Everyone Is Stuck in Their Zone' and (c) Wear and Tear of 'Continuous Exposure to Crisis and Chaos'. The themes interacted with systemic (Sisyphean Endeavours) and organisational issues (Occupationally Unsupported), intensifying the emotional burden of day-to-day work, which involved frequent crises and uncertainty (Wear and Tear of 'Continuous Exposure to Crisis and Chaos'). The findings underscore how these challenges threaten providers' wellness at work and have implications for the care provided to service users. Accordingly, the Quadruple Aim is a potentially useful and applicable framework for measuring the performance of PSH programs, which warrants further consideration in research and policy.

The use of eHealth interventions among persons experiencing homelessness: A systematic review.

OBJECTIVE: eHealth interventions are being developed to meet the needs of diverse populations. Despite these advancements, little is known about how these interventions are used to improve the health of persons experiencing homelessness. The aim of this systematic review was to examine the feasibility, effectiveness, and experience of eHealth interventions for the homeless population. METHODS: Following PRISMA guidelines, a systematic search of PsycINFO, PubMed, Web of Science, and Google Scholar was conducted along with forward and backward citation searching to identify relevant articles. RESULTS: Eight articles met eligibility criteria. All articles were pilot or feasibility studies that used modalities, including short message service, mobile apps, computers, email, and websites, to deliver the interventions. The accessibility, flexibility, and convenience of the interventions were valued by participants. However, phone retention, limited adaptability, a high level of human involvement, and preference for in-person communication may pose future implementation challenges. CONCLUSIONS: eHealth interventions are promising digital tools that have the potential to improve access to care and service delivery. eHealth interventions are feasible and usable for persons experiencing homelessness. These interventions may have health benefits by augmenting existing services and if implementation challenges are addressed. Further evaluation of the effectiveness of eHealth interventions is needed before widespread implementation. Those with lived experience should also be engaged in developing and evaluating these interventions.