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1.
Int J Law Psychiatry ; 68: 101515, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32033692

RESUMO

The Consent and Capacity Board (CCB) of Ontario is an independent administrative tribunal that adjudicates on matters of consent to medical treatment including involuntary admission to a psychiatric facility and findings of incapacity with regard to treatment decisions. This study explores the perspectives of multiple stakeholders on procedural justice in CCB hearings in Ontario. Using purposeful and snowball sampling, participants including CCB panel members and staff, patients, and other professionals (e.g., lawyers, psychiatrists) were recruited from different sites across the city of Toronto. Using focus groups (n = 10) and individual interviews (n = 14), data were collected from 44 participants including 6 patients and 38 other stakeholders who have participated in CCB hearings. Using thematic analysis, we identified five themes - (i) Inclusiveness (ii) Respect (iii) Fairness (iv) Finding and using one's voice, and (v) Balancing interests. Findings revealed that despite efforts by CCB panel members to conduct hearings in an inclusive manner, the legalistic nature of the proceedings, as well as patients' uncertainty regarding the benefits of testifying, may be perceived as barriers to patients' meaningful participation. There was a general belief that patients are respected during CCB hearings by physicians and panel members; however, patients and their lawyers had mixed perceptions about this issue. Almost all stakeholders, excluding CCB panel members, perceived that CCB hearings were not procedurally fair. Our findings indicate that CCB hearings, as currently conducted, are not perceived as procedurally just by many of the relevant stakeholders. This perception may improve by adopting a more informal and less adversarial hearing format as well as enhancing patients' education and understanding of the CCB hearings' processes and potential outcomes.

2.
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.

3.
Psychiatr Serv ; 71(1): 96-99, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31615367

RESUMO

This column describes the development of a partnership between health care, housing, and intellectual disability services to support efforts by homeless adults with intellectual disabilities to exit homelessness. Applying a Housing First approach and philosophy, the partners launched a pilot intervention, which at its first phase engaged 26 homeless adults with intellectual disabilities in Toronto. This cross-sector service model was acceptable to service users, who reported positive experiences and good program engagement. Key enablers of success included the program's capacity to address complexity, stakeholders' approach to choice and compromise, and fulsome collaboration and communication at every level.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31814189

RESUMO

Gender-based violence is associated with an elevated risk of physical and psychological harm for girls and women. This study examines service user and provider experiences of a trauma-informed, peer-facilitated group psychosocial intervention (Peer Education and Connection through Empowerment [PEACE]) targeting female-identified youth experiencing homelessness and gender-based violence. Participants were recruited among service users and providers of the intervention, delivered in Toronto, Canada. We conducted 19 semi-structured interviews between May and October 2017, engaging 12 service users and 7 additional stakeholders (including social service providers, peers and program administrators). We elicited participant perspectives on the acceptability of the intervention and key enablers of successful implementation and engagement of the target population. Qualitative transcripts were analysed using thematic analysis. Service users, including survivors of sexual exploitation, forced marriage and honour crimes, described satisfaction with and acceptability of the intervention. A number of factors were perceived by service users and providers as contributing to the intervention's successful implementation, including a focus on service user needs, program quality, flexibility and accessibility and strong inter-and intra-agency networks. Introducing peers as mentors led to challenges that could be mitigated through peer mentor education and training to maintain healthy boundaries and enhance peer mentor retention. The need for clear guidelines on the management of trauma disclosures in community settings and a systems-wide approach to service provider and administrator training in the effective integration of peer support services also emerged as important areas for future development. A group-based, trauma-informed and peer-supported psychosocial intervention was acceptable to service users and providers and successfully engaged female-identified survivors of gender-based violence who were also experiencing homelessness. Findings add to the scant knowledge base on interventions to support this population and identify important areas for future research.

5.
Lancet Psychiatry ; 6(11): 915-925, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31601530

RESUMO

BACKGROUND: Housing First is increasingly implemented for homeless adults with mental illness in large urban centres, but little is known about its long-term effectiveness. The At Home/Chez Soi randomised controlled trial done in five cities in Canada showed that Housing First improved housing stability and other select health outcomes. We extended the At Home/Chez Soi trial at the Toronto site to evaluate the long-term effects of the Housing First intervention on housing and health outcomes of homeless adults with mental illness over 6 years. METHODS: The At Home/Chez Soi Toronto study was a randomised, controlled trial done in Toronto (ON, Canada). Here, we present the results of an extension study done at the same site. Participants were homeless adults (aged ≥18 years) with a serious mental disorder with or without co-occurring substance use disorder. In phase 1, participants were stratified by level of need for mental health support services (high vs moderate), and randomly assigned (1:1) using adaptive randomisation procedures to Housing First with assertive community treatment (HF-ACT), Housing First with intensive case management (HF-ICM), or to treatment as usual (TAU). Participants with moderate support needs were further stratified by ethnoracial status. Considering the nature of the Housing First intervention, study participants and study personnel were not masked to group assignment. Phase 1 participants could choose to enrol in the extension study (phase 2). The primary outcome was the rate of days stably housed per year analysed in the modified intention-to-treat population, which included all randomly assigned participants who had at least one assessment for the primary outcome. Participants contributed data to the study up to the point of their last interview. Multilevel multiple imputation was used to handle missing data. The trial was registered with ISRCTN, ISRCTN42520374. FINDINGS: Between Oct 1, 2009, and March 31, 2013, 575 individuals participated in phase 1 of the Toronto Site At Home/Chez Soi study (197 [34%] participants with high support needs and 378 [66%] with moderate support needs). Of the 378 participants with moderate support needs, 204 were randomly assigned to receive the HF intervention with ICM or with ethnoracial-specific ICM services (HF-ER-ICM; HF-ICM or HF-ER-ICM groups) and 174 were randomly assigned to TAU. Of the 197 participants with high support needs, 97 were randomly assigned to receive the HF intervention with ACT (HF-ACT treatment group) and 100 were randomly assigned to TAU group. Between Jan 1, 2014, and March 31, 2017, 414 (81%) of 575 phase 1 participants participated in the extended phase 2 study. The median duration of follow-up was 5·4 years (IQR 2·1-5·9). Among phase 2 participants, 141 had high support needs (79 participants in the HF-ACT group; 62 participants in the TAU group), and 273 had moderate support needs (160 participants in the HF-ICM or HF-ER-ICM group; 113 participants in the TAU group). 187 high support needs participants (93 participants in the HF-ACT group, 94 participants in the TAU group), and 361 moderate support needs participants (201 participants in the HF-ICM or HF-ER-ICM group, 160 participants in the TAU group) were included in the modified intention-to-treat analysis for the primary outcome. The number of days spent stably housed was significantly higher among participants in the HF-ACT and HR-ICM or HF-ER-ICM groups than participants in the TAU groups at all timepoints. For participants with moderate support needs, the rate ratio (RR) of days stably housed in the Housing First group, compared with TAU, was 2·40 (95% CI 2·03-2·83) in year 1, which decreased to 1·13 (1·01-1·26) in year 6. The RR of days stably housed for participants with high support needs, compared with TAU, was 3·02 (2·43-3·75) in year 1 and 1·42 (1·19-1·69) in year 6. In year 6, high support needs participants in the Housing First group spent 85·51% of days stably housed compared with 60·33% for the TAU group, and moderate needs participants in the Housing First group spent 88·16% of days stably housed compared with 78·22% for the TAU group. INTERPRETATION: Rent supplements and mental health support services had an enduring positive effect on housing stability for homeless adults with mental illness in a large, resource-rich urban centre, with a larger impact on individuals with high support needs than moderate support needs. FUNDING: Mental Health Commission of Canada, Ontario Ministry of Health and Long-Term Care, and the Canadian Institute of Health Research.


Assuntos
Serviços Comunitários de Saúde Mental/métodos , Pessoas em Situação de Rua/psicologia , Pessoas em Situação de Rua/estatística & dados numéricos , Transtornos Mentais/terapia , Avaliação de Programas e Projetos de Saúde/métodos , Habitação Popular/estatística & dados numéricos , Adulto , Feminino , Seguimentos , Humanos , Masculino , Transtornos Mentais/psicologia , Ontário , Tempo , População Urbana/estatística & dados numéricos
6.
JAMA Netw Open ; 2(8): e199782, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31433483

RESUMO

Importance: In the At Home/Chez Soi trial for homeless individuals with mental illness, the scattered-site Housing First (HF) with Intensive Case Management (ICM) intervention proved more effective than treatment as usual (TAU). Objective: To evaluate the cost-effectiveness of the HF plus ICM intervention compared with TAU. Design, Setting, and Participants: This is an economic evaluation study of data from the At Home/Chez Soi randomized clinical trial. From October 2009 through July 2011, 1198 individuals were randomized to the intervention (n = 689) or TAU (n = 509) and followed up for as long as 24 months. Participants were recruited in the Canadian cities of Vancouver, Winnipeg, Toronto, and Montreal. Participants with a current mental disorder who were homeless and had a moderate level of need were included. Data were analyzed from 2013 through 2019, per protocol. Interventions: Scattered-site HF (using rent supplements) with off-site ICM services was compared with usual housing and support services in each city. Main Outcomes and Measures: The analysis was performed from the perspective of society, with days of stable housing as the outcome. Service use was ascertained using questionnaires. Unit costs were estimated in 2016 Canadian dollars. Results: Of 1198 randomized individuals, 795 (66.4%) were men and 696 (58.1%) were aged 30 to 49 years. Almost all (1160 participants, including 677 in the HF group and 483 in the TAU group) contributed data to the economic analysis. Days of stable housing were higher by 140.34 days (95% CI, 128.14-153.31 days) in the HF group. The intervention cost $14 496 per person per year; reductions in costs of other services brought the net cost down by 46% to $7868 (95% CI, $4409-$11 405). The incremental cost-effectiveness ratio was $56.08 (95% CI, $29.55-$84.78) per additional day of stable housing. In sensitivity analyses, adjusting for baseline differences using a regression-based method, without altering the discount rate, caused the largest change in the incremental cost-effectiveness ratio with an increase to $60.18 (95% CI, $35.27-$86.95). At $67 per day of stable housing, there was an 80% chance that HF was cost-effective compared with TAU. The cost-effectiveness of HF appeared to be similar for all participants, although possibly less for those with a higher number of previous psychiatric hospitalizations. Conclusions and Relevance: In this study, the cost per additional day of stable housing was similar to that of many interventions for homeless individuals. Based on these results, expanding access to HF with ICM appears to be warranted from an economic standpoint. Trial Registration: isrctn.org Identifier: ISRCTN42520374.

7.
BMC Health Serv Res ; 19(1): 482, 2019 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-31300051

RESUMO

BACKGROUND: Health utility assessments are important for economic evaluations but few instruments have been validated in homeless people with mental illness. We examined the convergent validity of the EuroQol-5 Dimension 3-level questionnaire (EQ-5D-3L) as a measure of quality of life in homeless adults with mental illness. METHODS: Data were from Toronto participants in At Home/Chez Soi, a 24-month randomized controlled trial of Housing First (immediate access to scattered site housing and mental health support services) compared to treatment as usual for homeless adults with a mental disorder (n = 575). Participants completed the EQ-5D-3L at 6 month intervals. We tested convergent validity, hypothesizing strong correlation (r > 0.6) with the Lehman Quality of Life Interview 20 (QOLI-20) index and moderate correlations (r > 0.3) with the Colorado Symptom Index (CSI), Recovery Assessment Scale (RAS), and number of comorbidities. We also examined correlations between EQ-5D-3L scores and the QOLI-20 over time using a linear mixed-effects model. RESULTS: The EQ-5D-3L was not strongly correlated with the QOLI-20 (r ranged from 0.31-0.52 at various time points). The EQ-5D-3L was moderately correlated with the CSI, RAS, and number of comorbidities. The Snijders/Bosker r2 for longitudinal validity between the EQ-5D-3L and QOLI-20 within subjects over time was 0.2094 (square-root r = 0.4576). CONCLUSIONS: The EQ-5D-3L did not demonstrate strong convergent validity in homeless people with mental illness but was moderately correlated with several instruments. Further research is warranted to determine the optimal method for measuring health utilities in this population. TRIAL REGISTRATION: International Standard Randomised Control Trial Registry ISRCTN42520374 assigned on August 18, 2009.


Assuntos
Pessoas em Situação de Rua/psicologia , Transtornos Mentais/epidemiologia , Qualidade de Vida , Inquéritos e Questionários , Adulto , Feminino , Pessoas em Situação de Rua/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
8.
Psychiatr Serv ; 70(11): 1053-1056, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31357920

RESUMO

OBJECTIVE: This study examined recent growth in demand for acute mental health and addiction (MHA) care in a large urban center and changes in patient flow following the expansion of a psychiatric emergency department (ED). METHODS: A retrospective observational design used administrative data in adjusted negative binomial regression models to identify time trends at seven hospitals over a 6-year period in central Toronto. Two-part linear spline models compared trends before and after a psychiatric ED expansion. RESULTS: Per capita MHA-related ED visits grew rapidly across the acute care system over the study period, although admissions per MHA ED visit decreased. Expanding a psychiatric ED did not influence overall system-level growth, but it significantly shifted traffic; the annual MHA ED visit growth rate increased at the expanded ED while decreasing at surrounding hospitals. CONCLUSIONS: Given increasing demand systemwide, individual hospital ED expansions may be inappropriate; planning should consider the whole system.

9.
JAMA Dermatol ; 2019 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-31166590

RESUMO

Importance: Previous studies suggest that depression and anxiety are common in patients with hidradenitis suppurativa (HS), more so than other dermatological conditions. Yet, to the authors' knowledge, no previous systematic review or meta-analysis has estimated the prevalence or odds ratio (OR) for those psychiatric comorbidities in this population. Objective: To assess the prevalence and odds for depression and anxiety in patients with HS. Data Sources: From July 25 to September 30, 2018, observational studies investigating the prevalence and odds for depression and anxiety in adults with HS were systematically searched without language restriction from the inception of each database to July 25, 2018, in PubMed/MEDLINE, Embase, and PsycINFO databases. Searches used various configurations of the terms hidradenitis suppurativa; acne inversa; depressive disorder; depression; anxiety; anxiety disorders; phobia, social; suicide; and suicide, attempted. In addition, the reference lists of included references were screened manually. Study Selection: Two investigators independently screened references that measured prevalence rates and odds for depressive and anxiety symptoms in patients with HS. Of 136 unique references, 10 ultimately met inclusion criteria. Data Extraction and Synthesis: Relevant data were extracted from eligible references. Authors were contacted to provide further information when necessary. Methodological quality of included studies was assessed through a modified version of the Newcastle-Ottawa Scale. Random-effects models were used to synthesize available evidence. Main Outcomes and Measures: Prevalence rates and ORs for depression and anxiety in adults with HS were the primary outcome measures. Heterogeneity across studies was assessed with the I2 statistic. Sources of heterogeneity were explored through subgroup and meta-regression analyses. Results: Ten studies comprising 40 307 participants with HS met inclusion criteria. The overall prevalence of depression was 16.9% (95% CI, 9.9%-27.2%). Heterogeneity was large. In the subgroup of studies that considered a clinical criteria-based diagnosis of depression, the prevalence of depression was 11.9% (95% CI, 4.9%-26.2%), compared with 26.8% (95% CI, 20.4%-34.5%) in studies that used a screening instrument. The methodological quality of included studies moderated those findings. The OR for depression in individuals with HS compared with individuals without HS was 1.84 (95% CI, 1.57-2.15). The prevalence of anxiety was 4.9% (95% CI, 1.7%-13.2%); there were insufficient data to determine an odds ratio for anxiety in persons with HS because 2 studies included a comparison group. Conclusions and Relevance: This systematic review and meta-analysis indicates that depression and anxiety are common comorbid conditions in patients with HS. Results suggest that the development of strategies to recognize and treat those psychiatric comorbidities in patients with HS is warranted.

10.
Int J Soc Psychiatry ; 65(6): 468-478, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31250692

RESUMO

BACKGROUND: Recovery education centers (RECs) offer recovery supports through education rather than traditional health services. The Supporting Transitions and Recovery Learning Centre (STAR) in Toronto, Canada, is among the few that are internationally focused on individuals with histories of homelessness. Although research suggests that RECs positively impact participants, there is a paucity of rigorous studies and none address the engagement and impacts on homeless individuals. AIMS: This protocol describes a realist-informed evaluation of STAR, specifically examining (1) if STAR participation is more effective in promoting 12-month recovery outcomes than participation in usual services for individuals experiencing housing instability and mental health challenges and (2) how STAR participation promotes recovery and other positive outcomes. METHODS: This study uses a quasi-experimental mixed methods design. Personal empowerment (primary outcome) and recovery, housing stability, social functioning, health service use and quality of life (secondary outcomes) data were collected at baseline, and 6 and 12 months. Intervention group participants were recruited at the time of STAR registration while control group participants were recruited from community agencies serving this population after screening for age and histories of housing instability. Interviews and focus groups with service users and providers will identify the key intervention ingredients that support the process of recovery. RESULTS: From January 2017 to July 2018, 92 individuals were recruited to each of the intervention and control groups. The groups were mostly similar at baseline; the intervention group's total empowerment score was slightly higher than the control group's (M (SD): 2.94 (0.23) vs 2.84 (0.28), p = .02), and so was the level of education. A subset of STAR participants (n = 20) and nine service providers participated in the qualitative interviews and focus groups. CONCLUSION: This study will offer important new insights into the effectiveness of RECs, and expose how key REC ingredients support the process of recovery for people experiencing housing instability.

11.
Can J Psychiatry ; 64(10): 718-725, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31248276

RESUMO

OBJECTIVE: We aimed to describe interactions between police and persons who experience homelessness and serious mental illness and explore whether housing status is associated with police interactions. METHOD: We conducted a secondary analysis of 2008 to 2013 data from the Toronto, Canada, site of the At Home/Chez Soi study. Using police administrative data, we calculated the number and types of police interactions, the proportion of charges for acts of living and administration of justice, and the proportion of occurrences due to victimization, involuntary psychiatric assessment, and suicidal behavior. Using generalized estimating equations, we estimated the odds of police interaction by housing status. RESULTS: This study included 547 adults with mental illness who were homeless at baseline. In the year prior to randomization, 55.8% of participants interacted with police, while 51.7% and 43.0% interacted with police in Study Years 1 and 2, respectively. Of 2,228 charges against participants, 12.6% were due to acts of living and 21.2% were for administration of justice. Of 518 occurrences, 41.1% were for victimization, 45.6% were for mental health assessment, and 22.2% were for suicidal behavior. The odds of any police interaction during the past 90 days was 47% higher for those who were homeless compared to those who were stably housed (95% CI 1.26 to 1.73). CONCLUSIONS: For people who experience homelessness and mental illness in Toronto, Canada, interactions with police are common. The provision of stable housing and changes in policy and practice could decrease harms and increase health benefits associated with police interactions for this population.

12.
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.

13.
Health Soc Care Community ; 27(4): 1053-1062, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30734374

RESUMO

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

14.
Can J Psychiatry ; 64(6): 415-422, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30616409

RESUMO

OBJECTIVES: Gender inequity in academic medicine persists despite increases in the number of women physicians. We sought to explore gender differences in research productivity for academic psychiatrists in Canada. METHODS: In a cross-sectional study of the 3379 psychiatrists in all 17 university departments of psychiatry in Canada, research productivity, as measured by the h-index and number of publications, was compared between women and men using a negative log binomial regression model to generate relative rates (RRs), adjusted for career duration (aRR). Findings were stratified by academic rank, institution region, and institution size. A subanalysis of those with 10 or more publications was conducted as a proxy for identifying physicians on a research track. RESULTS: Women (43% of the sample) had a lower mean (standard deviation) h-index than men (2.87 [6.49] vs. 5.31 [11.1]; aRR, 0.62; 95% confidence interval [CI], 0.54 to 0.72). Differences were significant only for junior faculty and not for associate and full professors. Comparison by number of publications followed a similar pattern (aRR, 0.46; 95% CI, 0.39 to 0.55). Among those with 10 or more publications (n = 721), differences between men and women were smaller than in the overall cohort for both the h-index (aRR, 0.77; 95% CI, 0.68 to 0.87) and number of publications (aRR, 0.62; 95% CI, 0.53 to 0.72). CONCLUSIONS: Gender differences in research productivity at the national level in academic psychiatry in Canada support a call to adopt a more systematic approach to promoting equitable opportunities for women in research, especially in early career, to improve diversity and enhance future psychiatric research and discovery.

15.
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.

16.
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
18.
Can J Psychiatry ; : 706743718782940, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29916270

RESUMO

OBJECTIVE: Housing First (HF) has been linked to increased tenure in housing for homeless people with mental illness, but the effect of HF on housing stability for people with borderline or lower intellectual functioning has not been examined. This study of homeless adults with mental illness in Toronto, Ontario assessed whether the association between housing stability and HF differed for adults with borderline or lower intellectual functioning, compared to adults with above borderline intellectual functioning. METHOD: This study included 172 homeless adults with mental illness from the Toronto site of the At Home-Chez Soi randomized trial that compared receiving HF relative to treatment as usual. This sample was divided into two intellectual functioning groups: 1) adults with borderline or lower intellectual functioning (IQ < 85, 16%), and 2) adults with above borderline intellectual functioning (IQ ≥ 85, 84%). We compared these groups by modelling the percentage of days stably housed using a linear multivariable generalized estimating equation and included interaction between treatment and intellectual functioning. An interaction between treatment and time was also included. RESULTS: There were no overall differences in housing stability for individuals with borderline or lower intellectual functioning compared to people with higher than borderline intellectual functioning in either the HF or the treatment as usual groups. CONCLUSION: This study is the first to demonstrate that for homeless adults with mental illness, borderline or lower intellectual functioning did not significantly affect housing stability. This accentuates the need for more research and potentially wider consideration of their inclusion in housing interventions, such as HF.

19.
Can J Psychiatry ; 63(11): 774-784, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29716396

RESUMO

OBJECTIVE: This study examines health and service use outcomes and associated factors among homeless adults participating in a brief interdisciplinary intervention following discharge from hospital. METHOD: Using a pre-post cohort design, 223 homeless adults with mental health needs were enrolled in the Coordinated Access to Care for the Homeless (CATCH) program, a 4- to 6-month interdisciplinary intervention offering case management, peer support, access to primary psychiatric care, and supplementary community services. Study participants were interviewed at program entry and at 3- and 6-month follow-up visits and assessed for health status, acute care service use, housing outcomes, mental health, substance use, quality of life, and their working alliance with service providers. Linear mixed models and generalized estimating equations were performed to examine outcomes longitudinally. Additional post hoc analyses evaluated differences between CATCH participants and a comparison group of homeless adults experiencing mental illness who received usual services over the same period. RESULTS: In the pre-post analyses, CATCH participants had statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions. The strength of the working alliance between participants and their case manager was associated with reduced health care use and mental health symptoms. Post hoc analyses suggest that CATCH may be associated with statistically significant improvements in mental health symptoms in the study population. CONCLUSIONS: A brief interdisciplinary intervention may be a promising approach to improving health outcomes among homeless adults with unmet health needs. Further rigorous research is needed into the effectiveness of brief interventions following discharge from hospital.


Assuntos
Assistência ao Convalescente/estatística & dados numéricos , Administração de Caso/estatística & dados numéricos , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Nível de Saúde , Pessoas em Situação de Rua/estatística & dados numéricos , Transtornos Mentais/terapia , Alta do Paciente/estatística & dados numéricos , Adulto , Assistência ao Convalescente/métodos , Assistência ao Convalescente/organização & administração , Feminino , Seguimentos , Humanos , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Modelos Estatísticos , Ontário/epidemiologia , Relações Profissional-Paciente , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde
20.
Can J Psychiatry ; : 706743718766053, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29614866

RESUMO

OBJECTIVE: Since the deinstitutionalization of psychiatric services around the world, the scope of outpatient psychiatric care has also increased to better support treatment access and adherence. For those with serious mental illness who may lack insight into their own illness, available interventions include coercive community practices such as mandated community treatment orders (CTOs). This paper examines the perceptions of coercion among service users treated with a CTO. METHOD: We used a cross-sectional comparative design where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services ( n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of the psychiatric treatment. RESULTS: The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, in adjusted analyses, service users' perception of coercion, irrespective of their CTO status, was directly correlated with their previous experience with probation and inversely correlated with the sense of procedural justice in their treatment. CONCLUSIONS: Evaluation of psychiatric service users' experiences of coercion should consider their past and current involvement with other types of coercive measures, particularly history of probation. Clinicians may be able to minimize these experiences of coercion by incorporating procedural justice principles into their practice.

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