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1.
J Urban Health ; 2020 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-32078728

RESUMO

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

2.
Can J Psychiatry ; : 706743720902616, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-31994918

RESUMO

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

3.
Artigo em Inglês | MEDLINE | ID: mdl-31925600

RESUMO

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.

4.
BMC Public Health ; 19(1): 1154, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31438912

RESUMO

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


Assuntos
Serviços Comunitários de Saúde Mental , Pessoas em Situação de Rua/psicologia , Habitação/estatística & dados numéricos , Transtornos Mentais/reabilitação , Adolescente , Adulto , Canadá , Cidades , Integração Comunitária , Feminino , Pessoas em Situação de Rua/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Qualidade de Vida , Índice de Gravidade de Doença , Adulto Jovem
5.
Eval Program Plann ; 75: 1-9, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30978474

RESUMO

We examined communities' expressed needs for capacity building in the implementation of Housing First (HF) for persons experiencing homelessness. The findings are based on thematic analyses of qualitative data obtained from participants (n = 77) in 11 focus groups conducted in seven Canadian cities. We identified capacity building needs in the areas of training (e.g., HF principles, clinical services, landlord engagement) and technical assistance (e.g., intake coordination, client prioritization, fidelity assessment). These findings were used to tailor training and technical assessment (TTA) to the stages of HF implementation in these cities. Limitations and implications for future theory, research, and practice are discussed.

6.
J Homosex ; : 1-19, 2019 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-31002582

RESUMO

This article examines entries into homelessness among adults who identify as LGBTQ2S (lesbian, gay, bisexual, transgender, queer, two-spirit). Twenty LGBTQ2S adults who were currently or formerly homeless participated in one qualitative interview. The interview protocol included questions on the participants' history of homelessness, causes of homelessness, and relationship of their gender and/or sexual identity to their homelessness. Data were analyzed using an iterative coding process. Results demonstrated that the participants listed both structural (i.e., discrimination) and intrapersonal (i.e., substance use) variables related to their homelessness. In particular, substance abuse was a common antecedent of their homelessness, and some participants linked their homeless experiences to discrimination and victimization based on their sexual and/or gender identity. The results are discussed in terms of interventions to prevent homelessness among LGBTQ2S adults and support their exits out of homelessness.

7.
Scand J Pain ; 19(3): 545-552, 2019 07 26.
Artigo em Inglês | MEDLINE | ID: mdl-31031261

RESUMO

Background and aims Chronic pain (CP) management presents a challenge for the healthcare system as many individuals experiencing CP cannot access appropriate services. Consequently, individuals may visit emergency departments (EDs) to address their CP, even though this setting is not the most appropriate. CP was identified as a common factor amongst patients with repeat ED use at a hospital in Ottawa, Canada. Thus, staff of the Pain Clinic developed the Rapid Interdisciplinary Pain Assessment Program to improve the care of patients with CP who had a minimum of 12 ED visits in the previous year, who were considered high frequency users (HFUs) of the ED. This evaluation was conducted to guide program improvements in advance of a clinical trial. The results are reported here in order to describe lessons that could be applied to the development of similar programs. The benefits of the program in reducing ED use, pain intensity, disability, and psychological distress have been described elsewhere (Rash JA et al. Pain Res Manag 2018:1875967). Methods Thirty-five people completed semi-structured interviews or a focus group, including eight patients, six ED staff, four primary care physicians (PCP), five Pain Clinic physicians, and 12 program staff members. Questions focused on the program's implementation, as well as strengths and areas for improvement. Results The program was generally consistent in offering the intended patients the services that were planned. Specifically, patients received an interdisciplinary assessment that informed the development of an assessment and treatment plan. These plans were shared with the PCP and added to the patient's hospital electronic medical record. Patients also received education about CP and had access to medical pain management, substance use, and psychological treatments. Inter-professional communication was facilitated by case conferences. Numerous aspects of the program were perceived as helpful, such as the quick access to services, the comprehensive assessment and treatment plans, the individualized treatment, the use of an interdisciplinary approach to care, and the communication and relationships with other care providers. However, challenges arose with respect to the coordination of services, the addition of supplementary services, the accessibility of the program, patients' perceptions of being misunderstood, communication, and relationship-building with other service providers. Conclusions The program sought to improve the care of HFUs with CP and reduce their ED use for CP management. The program had numerous strengths, but also encountered challenges. Developers of programs for HFUs with CP are encouraged to consider these challenges and suggested solutions. These programs have the potential to deliver effective healthcare to individuals with CP and reduce ED overutilization. Implications Our findings suggest that the following points should be considered in the development of similar programs: the inclusion of a case manager; the use of strategies to ensure inter-professional communication, such as secure electronic consultation, approaches to allow access to assessment and treatment plans, and offering a range of modalities for communication; holding regular case conferences; determining the appropriate types of services to offer; and working to address patients' fears of being labelled.

8.
J Community Psychol ; 47(1): 7-20, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30506925

RESUMO

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

9.
Int J Public Health ; 64(3): 399-409, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30382287

RESUMO

OBJECTIVES: To determine the relationship between housing instability, as measured by the number of residential moves, with problematic substance use, unmet healthcare needs, and acute care utilization. METHODS: A cohort of homeless or vulnerably housed persons from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396) completed interviewer-administered surveys at baseline and annually for 4 years from 2009 to 2013. Generalized mixed effects logistic regression models were used to examine the association between the number of residential moves and each of the three outcome variables, adjusting for potential confounders. RESULTS: The number of residential moves was significantly associated with higher acute care utilization [adjusted odds ratio (AOR) 1.25; 95% confidence interval (CI) CI: 1.17-1.33], unmet healthcare needs (AOR 1.14; 95% CI: 1.07-1.22), and problematic substance use (AOR 1.26; 95% CI: 1.16-1.36). Having chronic physical or mental conditions and recent incarceration were also found to be associated with the outcomes. CONCLUSIONS: Housing instability increased the odds of all three poor health metrics, highlighting the importance of stable housing as a critical social determinant of health.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Pessoas em Situação de Rua/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Habitação/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Populações Vulneráveis/estatística & dados numéricos , Adulto , Canadá/epidemiologia , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
10.
J Homosex ; 66(3): 297-323, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29206576

RESUMO

Little is known about lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults who experience homelessness. The current review critically analyzes the scant literature on LGBTQ adults who experience homelessness, with a particular focus on: (1) pathways into homelessness; (2) support needs; (3) targeted programming; and (4) exits out of homelessness. A total of 143 articles were identified, and 16 articles met the criteria of appropriate age range, article quality, and relevance of topic. Results from this review demonstrate that homeless LGBTQ adults have unique physical and mental health challenges, largely concerning HIV and substance use. Transgender and gender non-conforming adults who experience homelessness encounter several challenges in the homelessness system, particularly in regard to safety and gender-affirming supports. Recommendations focus on practical implications for support and suggestions for future research.


Assuntos
Pessoas em Situação de Rua , Minorias Sexuais e de Gênero , Feminino , Humanos , Masculino , Fatores de Risco
11.
Community Ment Health J ; 55(4): 631-640, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30519803

RESUMO

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.

12.
Am J Community Psychol ; 62(1-2): 135-149, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30106486

RESUMO

The scaling out of Housing First (HF) programs was examined in six Canadian communities, in which a multi-component HF training and technical assistance (TTA) was provided. Three research questions were addressed: (a) What were the outcomes of the TTA in terms of the development of new, sustained, or enhanced programs, and fidelity to the HF model? (b) How did the TTA contribute to implementation and fidelity? and (c) What contextual factors facilitated or challenged implementation and fidelity? A total of 14 new HF programs were created, and nine HF programs were sustained or enhanced. Fidelity assessments for 10 HF programs revealed an average score of 3.3/4, which compares favorably with other HF programs during early implementation. The TTA influenced fidelity by addressing misconceptions about the model, encouraging team-based practice, and facilitating case-based dialogue on site specific implementation challenges. The findings were discussed in terms of the importance of TTA for enhancing the capacities of the HF service delivery system-practitioners, teams, and communities-while respecting complex community contexts, including differences in policy climate across sites. Policy climate surrounding accessibility of housing subsidies, and use of Assertive Community Treatment teams (vs. Intensive Case Management) were two key implementation issues.


Assuntos
Serviços Comunitários de Saúde Mental/métodos , Habitação/organização & administração , Transtornos Mentais/reabilitação , Canadá , Administração de Caso , Serviços Comunitários de Saúde Mental/organização & administração , Pessoas em Situação de Rua , Humanos , Modelos Organizacionais , Desenvolvimento de Programas/métodos
13.
Psychiatr Rehabil J ; 41(4): 356-360, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29781639

RESUMO

OBJECTIVES: The purpose of this study was to determine the prevalence of tobacco use and overall smoking behaviors within a sample of individuals with a serious mental illness who were homeless or vulnerably housed and receiving community mental health services. METHODS: In 2010, individuals (N = 639) were interviewed, and identified smokers completed the Fagerström Test for Nicotine Dependence (FTND) and additional questions related to their smoking behaviors. RESULTS: Tobacco use prevalence was 72%, and 62% of smokers had high or very high levels of nicotine dependence. Smoking behaviors included smoking contraband cigarettes (47%) and smoking cigarettes remade from discarded cigarette butts (25%). Smokers were found to be over 9 times as likely to have a co-occurring substance use disorder. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Significant tobacco prevalence and dependency in this population highlights the need to provide integrated treatment opportunities. (PsycINFO Database Record (c) 2018 APA, all rights reserved).


Assuntos
Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Pessoas em Situação de Rua/estatística & dados numéricos , Habitação/estatística & dados numéricos , Fumar/epidemiologia , Tabagismo/epidemiologia , Adulto , Fumar Cigarros/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Prevalência
14.
Eval Program Plann ; 68: 166-175, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29605761

RESUMO

The purpose of this study was to test the construct validity of the Evaluation Capacity in Organizations Questionnaire (ECOQ). Conceptually, the ECOQ examines the role of evaluation in organizational development and, most notably in organizational learning. In this model, evaluation capacity building (ECB) initiatives are assumed to contribute to the development of a culture of systematic self-assessment and reflection, which, in turn, leads to increased organizational learning. Our sample consisted of internal evaluators within the federal, provincial or municipal government, not-for-profit organizations, private firms, and colleges or universities in Canada. Exploratory factor analysis (EFA) and latent path analysis (LPA) were conducted to better understand the underlying structural aspect of the organizational capacity to do and use evaluation construct as measured by the ECOQ. The results of our study indicate that the ECOQ effectively assesses an organization's capacity to do and use evaluation. Furthermore, evidence provided by the LPA statistical analysis suggests that an organization's capacity to learn is enhanced by the relationships among the various factors. Implications of using a validated model of an organization's capacity to do and use evaluations in both research and practice are discussed.


Assuntos
Fortalecimento Institucional/organização & administração , Organizações/organização & administração , Avaliação de Programas e Projetos de Saúde/métodos , Avaliação de Programas e Projetos de Saúde/normas , Inquéritos e Questionários/normas , Canadá , Fortalecimento Institucional/normas , Análise Fatorial , Humanos , Cultura Organizacional , Organizações/normas , Organizações sem Fins Lucrativos/organização & administração , Setor Privado/organização & administração , Setor Público/organização & administração , Reprodutibilidade dos Testes , Universidades/organização & administração
15.
J Dual Diagn ; 14(1): 21-31, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29494795

RESUMO

OBJECTIVE: Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study. METHODS: In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months. RESULTS: Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders. CONCLUSIONS: Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Nível de Saúde , Pessoas em Situação de Rua/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Habitação/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Populações Vulneráveis/estatística & dados numéricos , Adulto , Alcoolismo/epidemiologia , Alcoolismo/terapia , Canadá/epidemiologia , Comorbidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Substâncias/terapia
16.
BMC Health Serv Res ; 18(1): 190, 2018 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-29558927

RESUMO

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.


Assuntos
Pessoas em Situação de Rua/psicologia , Habitação/estatística & dados numéricos , Transtornos Mentais/terapia , Serviços de Saúde Mental/estatística & dados numéricos , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Pessoas em Situação de Rua/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais Psiquiátricos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Prisões/estatística & dados numéricos
17.
Am J Community Psychol ; 61(1-2): 118-130, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29251344

RESUMO

We present interim findings of a cross-site case study of an initiative to expand Housing First (HF) in Canada through training and technical assistance (TTA). HF is an evidence-based practice designed to end chronic homelessness for consumers of mental health services. We draw upon concepts from implementation science and systems change theory to examine how early implementation occurs within a system. Case studies examining HF early implementation were conducted in six Canadian communities receiving HF TTA. The primary data are field notes gathered over 1.5 years and evaluations from site-specific training events (k = 5, n = 302) and regional network training events (k = 4, n = 276). We report findings related to: (a) the facilitators of and barriers to early implementation, (b) the influence of TTA on early implementation, and (c) the "levers" used to facilitate broader systems change. Systems change theory enabled us to understand how various "levers" created opportunities for change within the communities, including establishing system boundaries, understanding how systems components can function as causes of or solutions to a problem, and assessing and changing systems interactions. We conclude by arguing that systems theory adds value to existing implementation science frameworks and can be helpful in future research on the implementation of evidence-based practices such as HF which is a complex community intervention. Implications for community psychology are discussed.


Assuntos
Pessoas em Situação de Rua , Habitação , Serviços de Saúde Mental , Canadá , Prática Clínica Baseada em Evidências , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde
18.
Int J Geriatr Psychiatry ; 33(1): 85-95, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28206715

RESUMO

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


Assuntos
Serviços Comunitários de Saúde Mental/métodos , Pessoas em Situação de Rua/psicologia , Transtornos Mentais/reabilitação , Habitação Popular , Adulto , Fatores Etários , Idoso , Administração de Caso , Feminino , Nível de Saúde , Humanos , Masculino , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Qualidade de Vida , Transtornos Relacionados ao Uso de Substâncias/psicologia , Adulto Jovem
19.
CMAJ Open ; 5(3): E576-E585, 2017 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-28724726

RESUMO

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

20.
J Dual Diagn ; 13(3): 219-229, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28414579

RESUMO

OBJECTIVES: This study explores the two-year housing- and non-housing-related outcomes for adults who are homeless with problematic substance use who received scattered-site housing and intensive case management services from a Housing First program in Ottawa, Canada, in comparison with a group of adults who are homeless with problematic substance use who had access to standard care in the community. METHODS: Housing First clients (n = 89) and members of a comparison group (n = 89) completed structured interviews at baseline and were followed for two years. RESULTS: Housing First clients moved into housing more quickly, reported a greater proportion of time housed, were more likely to spend the final six months housed, and had longer housing tenure at 24 months. There was a group by time interaction on problematic alcohol use with more rapid improvement for the comparison group; however, both groups improved over time. The comparison group had a greater decrease on problematic drug use by 24 months. There was no change in physical health and only the comparison group had improvements in mental health by 24 months. The groups had similar improvement on community functioning by 24 months. The comparison group had a greater increase in total quality of life. More specifically, the comparison group had an increase in the family relations-related quality of life, whereas the clients did not. There was a significant interaction for safety-related quality of life, but both groups experienced improvements over time and had comparable levels of satisfaction with safety at each time point. The Housing First clients reported higher levels of satisfaction with living conditions than the comparison group at baseline and 12 months, but not at 24 months. There was significant improvement over time and no main effect of group for finances, leisure, and social relations. CONCLUSIONS: Adults who are homeless with problematic substance use can successfully be housed using a Housing First approach. However, further targeted services might be required to address other areas of functioning, such as health, substance use, and quality of life.


Assuntos
Pessoas em Situação de Rua , Habitação , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Adulto , Cidades , Feminino , Humanos , Entrevistas como Assunto , Masculino , Ontário , Qualidade de Vida , Fatores de Tempo
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