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.

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.

Graduation practices and outcomes in intensive case management programs for severe mental illness: A systematic review.

OBJECTIVE: Intensive case management (ICM) is important in psychiatric rehabilitation but there is a need to "graduate" clients. The purpose of this research was to review the literature on criteria used and outcomes of graduating clients with severe mental illness from ICM programs. METHOD: A systematic review conducted in 2019 used keyword searches in all major research databases. This search yielded 1,142 articles which were distilled to 20 studies that reported a graduation process from an ICM program (11 studies), and/or reported clinical or psychosocial outcomes after graduation (15 studies). RESULTS: Three main methods have been used to determine graduation: Clinician judgment (n = 8 studies), rating scales (n = 4), or shared decision-making (n = 3). Across studies, graduation rates ranged from 1% to 25% over a 1-year period, 44% to 65% over a 2-year period, and 9% to 29% over a 4-year period. After graduation, 4%-14% of graduates had to be readmitted to ICM but 60% of studies reported positive client outcomes after graduation which included significant reductions in hospitalizations, and improvements in quality of life, unmet needs for care, and family relationships. Only two studies reported negative outcomes after graduation which included hospitalizations, homelessness, incarceration, and treatment drop-out. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: ICM programs can successfully graduate clients to less intensive services, and there are procedures available to guide graduation decisions but no universally agreed-upon method. Additional research is needed to identify optimal methods for graduation for different client populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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.

Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States.

Policy Points Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services. Drawing on extensive document reviews and in-depth interviews in four early-adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. CONTEXT: The Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports. METHODS: We conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think-tank reports, and published literature. We also conducted a systematic inductive qualitative analysis. FINDINGS: We identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd-out and waiver burden. CONCLUSIONS: Notwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start-up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.

Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness.

BACKGROUND: Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE: To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN: Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS: A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS: PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). CONCLUSIONS: Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

Negotiating child protection mandates in Housing First for families.

BACKGROUND: Housing First (HF) is an evidence-based service model that combines permanent housing and supportive case management premised on harm reduction and consumer self-determination to end homelessness for high-need individuals. Originally developed for use with single adults, this model is now being employed with families. Yet there is little empirical work on how HF is implemented with this particular population. OBJECTIVE: The aim of this study is to examine how frontline providers adapt and apply HF to formerly homeless or at-risk, families involved in child welfare. PARTICIPANTS AND SETTING: Frontline providers working in family HF programs (N = 59) were recruited from two states, across 11 organizations, and 16 program sites. The theoretical sample (n = 26) includes 13 participants working in programs that encouraged direct collaboration with Child Protective Services (CPS) in the program model and 13 participants from three non-CPS-aligned sites in a second state. METHODS: A grounded theory approach was used to analyze semi-structured, qualitative interviews. RESULTS: Frontline providers exercised street-level bureaucratic discretion when interpreting child protection reporting mandates and they found ways to adapt the HF model to this population. In doing so, they worked to juggle both their mandates to child protection and to principles of HF to create a "child safety-modified" form of HF. CONCLUSIONS: While our study shows that providers are modifying HF to address the needs of families involved in child welfare, it also raises questions as to the degree to which HF can be done with high fidelity when used with this population.

Moving On From Supportive Housing (MOSH): Development and evaluation of a transitional skill-building curriculum for providers helping residents exit homeless services.

This article describes the development and evaluation of MOSH (Moving On From Supportive Housing), a transitional skill-building curriculum for providers helping residents exit homeless services to mainstream housing without embedded supports. In this evaluation, we assess the feasibility, acceptability, fit, and potential efficacy of the MOSH curriculum to improve proximal provider-level outcomes, including self-efficacy to provide MOSH-related independent living skills and supports. Homeless-services providers (N = 49) from a range of programs and settings participated in the training. Findings from focus groups and pre- and posttest surveys indicate high levels of overall satisfaction with the training. The majority of trainees perceived the training to be useful to their work and potentially useful for service recipients, felt the training would fit well within their existing day-to-day work, and said they were very likely to use MOSH skills in such work. Statistically significant improvements in self-efficacy regarding all skills but one were also found. MOSH holds promise as an intervention that can enhance provider practice and promotion of independent living skills in homeless services. Although these initial findings on MOSH are encouraging, further research will be needed to evaluate provider knowledge gains and effective use of these skills in practice.

"I achieved being an adult": A Qualitative Exploration of Voluntary Transitions from Permanent Supportive Housing.

This study examined how individuals voluntarily leaving permanent supportive housing (PSH) through a Moving On initiative experienced the transition from PSH services to mainstream housing. Participants (N = 25) were purposively sampled from five supportive housing agencies in a Moving On initiative. A modified grounded theory approach was used to analyze semi-structured, post-move interviews. Participants described the transition from PSH as a process that involved gaining freedom from negative aspects of the PSH environment and a stagnation in services, adjusting to a new environment and the loss of familiar supports, taking on new responsibilities of self-advocacy and managing new financial burdens, and feeling empowered to move on to next steps, which ultimately, led to achievement of independence. Various contextual conditions, including PSH- and postmove housing type, influenced participants' experience of this process. Findings can inform future Moving On initiatives, implementation of PSH programs, as well as the design of the larger homeless service system.

Change in housing environment and residential satisfaction following exit from permanent supportive housing.

Moving On initiatives (MOIs) transition stable permanent supportive housing (PSH) residents into mainstream housing without embedded services. While this approach frees up PSH for homeless individuals in need, open questions remain regarding MOI recipients' long-term outcomes. This exploratory study examines how housing environment and residential satisfaction, potential predictors of housing retention, change from PSH to mainstream housing. Subjective assessments of housing and neighborhood quality and residential satisfaction, as well as objective neighborhood-level data, are used to examine housing-related change for New York City MOI recipients. Participants generally moved to less-distressed neighborhoods with lower poverty and crime. Subjective perceptions of some aspects of neighborhood and housing quality also improved post-move. Participants tended to move farther from public transportation but were on average located within one mile of the nearest subway station. Results can be taken as early indicators of the potential benefits of MOIs.

Strategies for Sustaining Fidelity: A Multi-state Qualitative Analysis in Housing First Programs.

Little is known about long-term fidelity of evidence-based interventions (EBIs) under changing conditions. This study examines how staff at 'mature' (eight or more years in operation) Housing First (HF) programs strategize to sustain EBI fit in different geographic areas in the Mid-Atlantic/Northeastern United States. Six focus groups (FGs) at three purposively selected HF programs were conducted with separate FGs for case managers and supervisors at each site. FG discussions elicited participants' service approaches and strategies in addressing fidelity amidst ongoing changes affecting each program. Thematic content analysis of FG transcripts was conducted using the five HF fidelity domains (housing choice/structure, separation of housing and services, service philosophy, service array, and program structure) as a priori themes with inductive content analyses conducted on data in each theme. Strategies for rigor were employed. Case managers (N = 17) and supervisors (N = 16) were predominantly white (76%) and female (60%). Across the themes, challenges included lack of affordable housing and choice, funders' restrictions and practice 'drift.' Strategies included community engagement and hiring, strong leadership and 'bending the rules.' There were no differences across sites. Later-stage implementation challenges show the need for continued vigilance in fidelity to EBIs. Among the strategies used to address fidelity in this study, the pursuit of pro-active community engagement to attract knowledgeable staff as well as increase local buy-in was considered pivotal at all three sites. These findings underscore the need to attend to the external setting as well as to internal program operations.

Community integration when moving on from permanent supportive housing.

AIMS: This study explored community integration within a Moving On initiative that assisted individuals with the transition from permanent supportive housing (PSH) to more independent housing without service requirements. METHODS: Participants completed baseline interviews while in PSH (n = 90) and, for those who moved on, a follow-up 1-year post-move (n = 45). Bivariate analyses and OLS regression were used to examine community integration outcomes and potential correlates. RESULTS: For participants who moved on, subjective social quality of life and sense of community were higher post-move, while physical integration decreased, and time spent at home increased. Gender, mastery, and housing quality were associated with community integration post-move. CONCLUSION: Moving On did not adversely impact most aspects of community integration, though PSH residents may need more support to facilitate participation in routine activities outside their home post-move. Findings also highlight the importance of supporting mastery given its potential role in community integration.

Stakeholder Perspectives on Implementation Challenges and Strategies for Moving On Initiatives in Permanent Supportive Housing.

Moving On Initiatives (MOIs) assist individuals with the transition from permanent supportive housing to mainstream housing without the embedded supports. This emerging innovation has the potential to increase behavioral health system capacity and provide recipients with the opportunity to live in the least restrictive setting. However, few empirical studies have examined MOIs, and little is known about the implementation challenges providers face and strategies they use to realize these initiatives in practice. To identify these challenges and strategies, this study utilized over 2 years of observations at MOI "learning collaboratives," as well as eight focus groups with implementation stakeholders. Analyses informed by the Consolidated Framework for Implementation Research (CFIR) identified challenges in the outer and inner service settings, as well as at the individual and innovation level. Outer setting challenges were most prominent in the data, and one non-CFIR construct, macrosystemic characteristics arose inductively. Implications for behavioral health policy and practice are discussed.

Medicaid Utilization and Spending among Homeless Adults in New Jersey: Implications for Medicaid-Funded Tenancy Support Services.

Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and reduce avoidable hospital costs for homeless populations. Compared with nonhomeless adult Medicaid beneficiaries, homeless adult beneficiaries have higher levels of health care needs, due in part to mental health issues and substance use disorders. Homeless adults are also more likely to visit the emergency department or require inpatient admissions. Emergency care and inpatient admissions may sometimes be avoided when individuals have high-quality community-based care and healthful living conditions. Offering tenancy support services that help homeless adults achieve stable housing may therefore be a cost-effective strategy for improving the health of this vulnerable population while reducing spending on avoidable health care interventions. Medicaid beneficiaries with disabling health conditions and more extensive histories of homelessness experience the most potentially avoidable health care interventions and spending, with the greatest opportunity to offset the cost of offering tenancy support benefits. CONTEXT: Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending. METHODS: Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries. FINDINGS: More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups. CONCLUSIONS: A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.

Employment experiences of formerly homeless adults with serious mental illness in Housing First versus treatment first supportive housing programs.

OBJECTIVE: This paper examines how formerly homeless adults with serious mental illness living in Housing First (HF) and "treatment first" (TF) supportive housing programs experience employment. Research questions include: How do these individuals experience employment in the context of their mental health recovery? What do they perceive as the benefits of and obstacles to attaining employment? Are there programmatic differences in their employment experiences? METHOD: Case study analyses of data from a federally funded qualitative study were conducted of 40 individuals purposively sampled from HF and TF programs. Data were independently analyzed and consensually discussed to develop cross-case themes. RESULTS: Three themes emerged: (a) the meaning of work, (b) working within the system, and (c) balancing treatment requirements and work. While none of the study participants had full-time jobs, more HF program clients had part-time employment than their TF counterparts. Of the 12 employed participants, all but 2 worked within their respective programs. Participants in both groups described similar benefits of obtaining employment, but TF program requirements inhibited job-seeking. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings provide insight into the challenges of obtaining employment for formerly homeless individuals with serious mental illness residing in supportive housing. Despite the motivation to work, individual, structural, and organizational factors impeded employment. To address this problem, factors at each of these levels will need to be considered. Interventions such as supported employment offer promise to supportive housing programs committed to employment as a contributor to recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

"How do we force six visits on a consumer?": Street-level dilemmas and strategies for person-centered care under Medicaid fee-for-service.

This qualitative study examines the delivery of person-centered care in Medicaid-funded supportive housing for adults with serious mental illness. While much work has been done to promote the uptake of a person-centered approach in healthcare, less is known about how this approach functions in homeless services and supportive housing where many individuals with mental health issues receive rehabilitative services. A total of 84 semi-structured interviews were collected from a purposeful sample of 35 frontline providers. Transcripts were analyzed inductively using Boytazis' thematic analysis. Three principle themes characterize the dilemmas experienced by street-level workers in these programs: (1) Putting the "consumer first" vs. achieving maximum billing; (2) Doing the "real work" vs. paperwork; and (3) Juggling clinical supervision vs. administrative oversight. In order to meet the demands of Medicaid, as well as the expectation for person-centered care delivery, providers enacted several discretionary strategies at the street-level: (1) Staying late and taking work home; (2) Padding the numbers; (3) Offering service recipients small choices; (4) Redirecting small talk to get to billable goal talk; and (5) Keeping consumers home. Findings highlight tensions between the accountability-focused fee-for-service model and the prioritization of consumer choice and individualization of services in person-centered care delivery.

"The Apartment is for You, It's Not for Anyone Else": Managing Social Recovery and Risk on the Frontlines of Single-Adult Supportive Housing.

This multi-method qualitative study examines frontline provider perspectives on consumer social relationships and barriers to social recovery in supportive housing programs for adults with serious mental illness. Thematic analyses show that guest and occupancy policies that enforce the "single" nature of single-adult supportive housing challenge consumer rights to self-determination in the realm of social recovery. Findings also highlight the ways in which providers act to reinforce and subvert these policies while mitigating risk in this service setting. Recommendations for enhancing the recovery orientation of supportive housing and implications for the design of the homeless service system are discussed.