Do Medicaid Expenditures Increase After Adults Exit Permanent Supportive Housing?

The effects of homelessness and permanent supportive housing (PSH) on health care utilization have been well documented. Prior research on the association between PSH entry and Medicaid expenditures have indicated that such housing support could result in savings to Medicaid programs; however, whether changes occur in health care use and expenditures after individuals exit PSH is unknown. If efficiency gains from PSH persist after the individual leaves PSH, the savings to payers such as Medicaid may continue even after the costs to provide housing for a PSH recipient have ended. We used linked Medicaid and housing data from Pennsylvania to examine changes in the level and composition of Medicaid expenditures for 580 adult enrollees during the 12 months before and after exit from PSH adjusting for relevant covariates. In adjusted analyses, we estimated that monthly spending declined by $200.32 (95% CI: $323.50, $75.15) in the first quarter post-exit and by $267.63 (95% CI: $406.10, $127.10) in the third quarter. Our findings suggest that PSH may have sustained budgetary benefits to state Medicaid agencies even for beneficiaries exiting the program. However, more research is needed to understand if these reductions in expenditures last beyond 12 months and do not reflect under-use of care that may be important for managing health over the long-term.

Profiles of Permanent Supportive Housing Residents Related to Their Housing Conditions, Service Use, and Associated Sociodemographic and Clinical Characteristics.

As permanent supportive housing (PSH) is the main strategy promoted to reduce homelessness, understanding how PSH resident profiles may be differentiated is crucial to the optimization of PSH implementation - and a subject that hasn't been studied yet. This study identified PSH resident profiles based on their housing conditions and service use, associated with their sociodemographic and clinical characteristics. In 2020-2021, 308 PSH residents from Quebec (Canada) were interviewed, with K-means cluster analysis produced to identify profiles and subsequent analyses to compare profiles and PSH resident characteristics. Of the three profiles identified, Profiles 1 and 2 (70% of sample) showed moderate or poor housing, neighborhood, and health conditions, and moderate or high unmet care needs and service use. Besides their "moderate" conditions, Profile 1 residents (52%) reported being in PSH for more than two years and being less educated. With the "worst" conditions and high service use, Profile 2 (18%) included younger individuals, while Profile 3 (30%) showed the "best" conditions and integrated individuals with more protective determinants (e.g., few in foster care, homelessness at older age, more self-esteem), with a majority living in single-site PSH and reporting higher satisfaction with support and community-based services. Profiles 1 and 2 may be provided with more psychosocial, crisis, harm reduction, and empowerment interventions, and peer helper support. Profile 2 may benefit from more intensive and integrated care, and better housing conditions. Continuous PSH may be sustained for Profile 3, with regular monitoring of service satisfaction and met needs.

Supporting Stabilization: A Qualitative Evaluation of a Pilot Program to Integrate Personal Caregiving Services Into Housing Settings.

Three organizations in Clark County, WA, partnered together to implement a pilot program to expand access to personal caregiving services in the homeless crisis response system. The aim of this study is to describe staff and clients' experiences of the program and its impact on clients' daily living activities, health and wellbeing, and housing stability. Using a qualitative descriptive design, semi-structured, in-depth interviews were conducted with 12 clients and 5 pilot staff, representing 4 housing service providers. Interviews were analyzed descriptively to examine staff and clients' perspectives and experiences with the personal care services pilot program. Caregivers helped clients establish routines, find companionship, and connect to health and social services both logistically and socioemotionally, supporting clients' stabilization and reducing barriers to healthcare. Hiring and retaining caregivers remained difficult due to the challenging nature of the work. Staff interviews highlight the need for additional supports to better retain caregivers. Findings from the evaluation have important implications for addressing the needs of individuals exiting homelessness and suggest that personal caregivers can play an important role in supporting the stabilization process. However, employing strategies such as training and increasing wages and benefits that support the needs of the caregiving workforce is essential to sustain this type of service delivery model.

College focused rapid rehousing: Deploying an existing community model to address homelessness on campus.

Research indicates that financial and housing insecurity challenges are widespread on most college campuses throughout the U.S. However, there is wide variability in how campuses address these challenges. This study reports on a three-year implementation of the College-Focused Rapid Rehousing pilot; an initiative in California by which universities commissioned community providers to assist students in need via a modified Rapid Rehousing (RRH) intervention. RRH is a widely implemented intervention that combines move-in assistance, short-term rental subsidies, and ongoing case management, to help individuals quickly transition into stable housing. The mixed-methods evaluation included analyses of online surveys (n = 141), administrative records (n = 368), and focus groups conducted with staff across eight campuses (n = 35). Survey findings indicate that CFRR programs assisted a diverse group of students with similar histories of housing insecurity. Quantitative analyses also show that most participants experienced the intervention as designed, though with some inconsistencies in how quickly some were assisted. Qualitative findings highlight contextual factors that affected the consistency of the intervention, including tight rental markets and philosophical disagreements among administrators about the intervention's scope. Despite study limitations, findings provide insights into the applicability of the RRH model on campus settings and directions for future research.

Changes in Medication Utilization and Adherence Associated with Homeless Adults' Entry into Permanent Supportive Housing.

BACKGROUND: Permanent supportive housing (PSH) programs, which have grown over the last decade, have been associated with changes in health care utilization and spending. However, little is known about the impact of such programs on use of prescription drugs critical for managing chronic diseases prevalent among those with unstable housing. OBJECTIVE: To evaluate the effects of PSH on medication utilization and adherence among Medicaid enrollees in Pennsylvania. DESIGN: Difference-in-differences study comparing medication utilization and adherence between PSH participants and a matched comparison cohort from 7 to 18 months before PSH entry to 12 months post PSH entry. SUBJECTS: Pennsylvania Medicaid enrollees (n = 1375) who entered PSH during 2011-2016, and a propensity-matched comparison cohort of 5405 enrollees experiencing housing instability who did not receive PSH but received other housing services indicative of episodic or chronic homelessness (e.g., emergency shelter stays). MAIN MEASURES: Proportion with prescription fill, mean proportion of days covered (PDC), and percent adherent (PDC ≥ 80%) for antidepressants, antipsychotics, anti-asthmatics, and diabetes medications. KEY RESULTS: The PSH cohort saw a 4.77% (95% CI 2.87% to 6.67%) relative increase in the proportion filling any prescription, compared to the comparison cohort. Percent adherent among antidepressant users in the PSH cohort rose 7.41% (95% CI 0.26% to 14.57%) compared to the comparison cohort. While utilization increased in the other medication classes among the PSH cohort, differences from the comparison cohort were not statistically significant. CONCLUSIONS: PSH participation is associated with increases in filling prescription medications overall and improved adherence to antidepressant medications. These results can inform state and federal policy to increase PSH placement among Medicaid enrollees experiencing homelessness.

Pilot Implementation of a Nutrition-Focused Community-Health-Worker Intervention among Formerly Chronically Homeless Adults in Permanent Supportive Housing.

Food insecurity is a known health equity threat for formerly chronically homeless populations even after they transition into permanent housing. This project utilized a human-centered design methodology to plan and implement a nutrition-focused community-health-worker (CHW) intervention in permanent supportive housing (PSH). The project aimed to increase access to healthy foods, improve nutritional literacy, healthy cooking/eating practices, and build community/social connectedness among 140 PSH residents. Validated food-security screening conducted by CHWs identified low or very low food security among 64% of 83 residents who completed the baseline survey, which is similar to rates found in a previous study among formerly homeless populations placed in PSH. Major themes identified through an analysis of resident feedback include (1) lack of needed kitchenware/appliances for food preparation, (2) knowledge gaps on how to purchase and prepare healthier food, (3) positive perceptions of healthy food options, (4) expanded preferences for healthy, easy-to-prepare foods, (5) regaining cooking skills lost during homelessness, (6) positive experiences participating in group activities, (7) community re-entry, and (8) resident ownership. Preliminary findings suggest the use of a human-centered design methodology for planning and implementing this multi-level CHW intervention helped reduce food insecurity, engaged participants in learning and adopting healthy and safe cooking and eating practices, and fostered social connectedness and feelings of community among formerly chronically homeless PSH residents.

Variables Associated with Quality of Life Among Individuals Living in Permanent Supportive Housing.

This study identified individual sociodemographic and clinical characteristics and service use patterns associated with quality of life (QoL) among 308 individuals living in permanent supportive housing (PSH) in Québec (Canada). Data were collected between 2020 and 2022, and linear multivariate analyses produced. Results demonstrated that better individual psychosocial conditions were positively associated with higher QoL. As well, living in PSH located in good neighborhoods for at least 5 years, higher self-esteem and community integration were positively associated with greater QoL. Met needs, satisfaction with housing support services, and no use of acute care were also linked with positive QoL. Comprehensive efforts to improve treatment for mental health disabilities responsive to the needs of PSH residents, and sustained long-term housing may reinforce QoL. Encouraging active participation in community-based activities, incorporating biophilic design into the neighborhoods around PSH, and promoting satisfaction with care may also enhance QoL.

Promoting Sustainability in Housing with Services: Insights From the Right Care, Right Place, Right Time Program.

Despite the widely-acknowledged potential of housing with services for improving the lives of low-income older adults, ensuring their financial sustainability has been challenging. This study aimed to address this issue, drawing on 31 key informant interviews and three focus groups with payers, housing providers, and community partners involved in the Boston-area Right Care, Right Place, Right Time Program, which enrolled about 400 older adults. Transcripts were qualitatively analyzed using thematic coding. Participants agreed on the program's value, but there was little consensus on mechanisms for securing ongoing funding. The broadly distributed responsibility for individuals in housing sites, which involves health insurers, hospitals, and community service providers, provides little incentive for investment by these entities. Findings suggest that governmental mechanisms, probably at the federal level, are needed to channel funding toward these supportive services. Without such reliable funding sources, replication of supportive housing models for low-income older people will prove difficult.

Risk of dementia among veterans experiencing homelessness and housing instability.

BACKGROUND: In the United States, nearly 85,000 Veterans experienced homelessness during 2020, and thousands more are experiencing housing instability, representing a significant proportion of the population.1 Many Veterans experiencing homelessness are aging and have complex co-occurring medical, psychiatric, and substance use disorders. Homelessness and older age put Veterans at greater risk for age-related disorders, including Alzheimer's disease and related dementias (ADRD). METHODS: We examined the rate of ADRD diagnosis for Veterans experiencing homelessness and housing instability compared to a matched cohort of stably housed Veterans over a nine-year period using cox proportional hazard models. RESULTS: In the matched cohort, 95% (n = 88,811) of Veterans were men, and 67% (n = 59,443) were White and were on average 63 years old (SD = 10.8). Veterans with housing instability had a higher hazard of 1.53 (95% confidence interval (CI) 1.50, 1.59) for ADRD compared to Veterans without housing instability. CONCLUSIONS: Veterans experiencing housing instability have a substantially higher risk of receiving an ADRD diagnosis than a matched cohort of stably housed Veterans. Health systems and providers should consider cognitive screening among people experiencing housing insecurity. Existing permanent supportive housing programs should consider approaches to modify wraparound services to support Veterans experiencing ADRD.

Using the matrixed multiple case study methodology to understand site differences in the outcomes of a Hybrid Type 1 trial of a peer-led healthy lifestyle intervention for people with serious mental illness.

Site differences in implementation trial outcomes are common but often not examined. In a Hybrid Type 1 trial examining the effectiveness-implementation of a peer-led group life-style balance (PGLB) intervention for people with serious mental illness (SMI) in three supportive housing agencies, we found that PGLB recipients' physical health outcomes differed by study sites. The matrixed multiple case study methodology was used to explore how implementation outcomes and changes in context of usual care (UC) services contributed to these site differences. Two implementation outcomes (i.e. PGLB fidelity ratings and intervention recipients' acceptability of PGLB and UC) and changes in healthcare services integration at the study sites were examined. ANOVAs were used to examine site differences in fidelity ratings and client satisfaction. Directed content analysis was used to analyze leadership interviews to identify changes in the context of UC services. Site 3 showed a trend approaching significance (P = .05) towards higher fidelity ratings. High levels of satisfaction with PGLB were reported at all sites. Significant differences in PGLB recipients' satisfaction with UC were found, with Site 3 reporting the lowest levels of satisfaction. Agency leaders reported an increase in prioritizing client's health throughout the trial with sites differing in how these priorities were put into action. Differences in PGLB recipients' satisfaction with UC, and changes in healthcare service integration seemed to have contributed to the site differences in our trial. The matrixed multiple case study methodology is a useful approach to identify implementation outcomes contributing to the heterogeneity of multisite implementation trial results.

A healthy lifestyle intervention delivered by people with lived experience of serious mental illness (SMI) led to improved health outcomes among participants living with SMI in three supportive housing agencies, but these outcomes differed by study sites. This study aimed to identify which factors influenced these site differences in study outcomes by examining if the intervention was delivered as intended, intervention recipients' satisfaction with the intervention and the pre-existing health care services delivered at each study site, and what changes occurred in health care services offered at each of the supportive housing agencies throughout the study. The intervention was found to have high levels of satisfaction across all three agencies but the agency which had the best outcomes also had the highest levels of intervention delivery adherence and the lowest levels of intervention recipients' satisfaction with existing health care services. Additionally, during the study period, the same agency described minimal changes in their existing health care services while the other two agencies were found to have made more significant changes integrating health care services to their day-to-day operations. As a result, findings from this study emphasize the importance of understanding the context in which interventions are delivered in routine practice settings to ensure their overall success.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review.

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Out-of-home interventions for adolescents who were treated according to the Open Dialogue model for mental health care.

BACKGROUND: The Open Dialogue approach (OD) emphasizes community-based psychiatric treatment for adolescents, but its success in achieving this is poorly documented. OBJECTIVE: To analyse out-of-home intervention usage in a national sample of adolescent psychiatric patients and determine if OD is linked to increased time until out-of-home intervention. PARTICIPANTS AND SETTING: The register-based cohort study included all adolescents aged 13-20 who received psychiatric treatment in Finland between 2003 and 2008. The research group (n = 780) included adolescents whose treatment was initiated in the Western Lapland catchment area, where OD covered the entire psychiatric service. The comparison group (n = 44,088) included the rest of Finland. National register data encompassed the period from treatment onset until the end of the 10-year follow-up or death. The primary outcomes of interest were the times to the first and second out-of-home intervention, including foster care, supportive housing, and hospitalization. The secondary outcomes included the clinical/demographic characteristics of adolescents treated out-of-home. METHODS: The hypothesis was tested via an inverse probability of treatment-weighted Cox hazard model, plus within- and between-group comparisons to analyse the secondary outcome. RESULTS: OD was associated with increased time to the first (adjusted hazard ratio [aHR]: 0.61, 95%CI: 0.52-0.72) and second (aHR: 0.75, 95%CI: 0.58-0.96) out-of-home interventions. In both service types, there was a subgroup of adolescents with repeated out-of-home interventions, who also demonstrated poorer long-term outcomes. CONCLUSION: OD-based psychiatric services for adolescents are associated with fewer out-of-home interventions. The clinical significance of the findings warrants further research.

"They are always focusing on the person who is doing the worst": Exploring how crisis shapes young people's pathways in and out of supportive housing in Vancouver, Canada.

Housing instability, homelessness, and mental health among young people who use drugs in Vancouver, Canada, and elsewhere have increasingly been framed through a language of crisis. The declaration of overlapping housing, mental health, and addictions crises in our own setting has prompted a wide range of interventions, including the rapid expansion of supportive housing programs that include integrated housing-based substance use and mental health care. There is growing evidence demonstrating that these models are effective at stabilizing people who are experiencing protracted housing instability, mental health, and substance use related health concerns. We recount stories of three young people who have lived in supportive housing to argue that achieving the relative stability afforded by these interventions is partially contingent on maintaining a delicate balance between being in a state of "too much" or "too little" in crisis. These stories demonstrate two key findings. First, being in crisis has made these young people visible to housing, substance use, and mental health programs that may not otherwise be available to them. Secondly, entering periods of protracted or intense mental health crisis may reopen pathways into unstable housing and homelessness by activating undesirable institutional responses that conflict with young people's desire for self-determination in relation to their care. This study underscores that supportive housing should be part of a broader youth focused system of housing and care that seeks to address the needs of young people before they enter states of crisis.

Life Meaning in a Social Context Among Formerly Homeless Residents of Permanent Supportive Housing.

Objective: Experiencing a life of meaning is considered fundamental to "what makes life worth living," yet investigation of life meaning among persons with lived experiences of homelessness is lacking. This study seeks to understand life meaning among formerly homeless residents of permanent supportive housing through an examination of its association with social context. Method: Data were collected through interviews with 383 persons with experience of chronic homelessness who were provided permanent supportive housing (PSH). Recruitment of participants occurred through partnerships with 26 providers of PSH in Los Angeles County, California. Multivariate logistic regression models were employed to understand association of life meaning with hypothesized social contextual variables, controlling for demographic and background characteristics. Results: Community integration and sense of belonging were significantly and positively associated with life meaning, consistent with findings from previous research involving persons not identified as experiencing homelessness. Conclusions: Findings suggest opportunities for service providers to facilitate life meaning among residents of supportive housing. Specific attention to life meaning and its social context is consistent with the World Health Organization's position that well-being is a significant aspect of health.

Changes in Health Care Utilization and Associated Costs After Supportive Housing Placement by an Urban Community Mental Health Center.

Permanent supportive housing (PSH) for individuals experiencing homelessness and living with mental illness can reduce utilization of crisis care services and increase utilization of outpatient care, although the extent to which pre-housing utilization patterns influence post-housing utilization remains unclear. Therefore, pre- and post-housing health service utilization was examined in 80 individuals living with a chronic mental illness who were and were not utilizing health care services in the years pre- and post-housing. Overall, the proportion of tenants utilizing outpatient services, including outpatient behavioral health services, increased from pre- to post-housing. Tenants who did not use outpatient behavioral health services prior to housing were disproportionately less likely than their peers to use those services after being housed. Among tenants who utilized crisis care services prior to being housed, reductions were observed in the number of crisis care visits. Results suggest PSH leads to changes in health care utilization and associated costs.

Investigating the Comparative Effectiveness of Place-Based and Scatter-Site Permanent Supportive Housing for People Experiencing Homelessness During the COVID-19 Pandemic: Protocols for a Mixed Methods, Prospective Longitudinal Study.

BACKGROUND: Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. OBJECTIVE: This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. METHODS: People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. RESULTS: Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. CONCLUSIONS: Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. TRIAL REGISTRATION: ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46782.

Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing.

BACKGROUND: Older adults experiencing chronic homelessness (i.e., prolonged homelessness and a disabling condition) have low rates of advance care planning (ACP) despite high rates of morbidity and mortality. Rehousing of homeless-experienced individuals into permanent supportive housing (PSH) may present an opportunity to introduce ACP; but this is unknown. Therefore, we explored staff and resident perceptions of conducting ACP in PSH. METHODS: We conducted semi-structured interviews with PSH staff (n = 13) and tenants (PSH residents) (n = 26) in San Francisco. We used the capability (C), opportunity (O), motivation (M), behavior (COM-B) framework within the Behavior Change Wheel model and the Theoretical Domains Framework (TDF) to inform interviews, categorize themes, and guide qualitative thematic analysis. RESULTS: The mean age of PSH residents was 67 (SD = 6.1) years and 52% were women. Of staff, 69% were women. Important COM-B barriers included ACP complexity (C), complicated relationship dynamics (O), resource limitations (O), pessimism (M), variable staff confidence (M), and competing priorities (M). Facilitators included easy-to-use documents/videos, including the PREPARE for Your Care program (C), stability with housing (O), exposure to health crises (O), potential for strong relationships (O), and belief that ACP is impactful (M). Recommendations included adapting materials to the PSH setting, providing staff trainings/scripts, and using optional one-on-one or group sessions. CONCLUSIONS: We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH. Future interventions should include using easy-to-use ACP materials and developing resources to educate PSH residents, train staff, and model ACP in groups or one-on-one sessions.

Homeowner perspectives on the implementation of the Community Homes for Opportunity (CHO) program: an ethnographic group homes study in Southwestern Ontario Canada.

BACKGROUND: The global extant literature acknowledge that housing serves as a key social determinant of health. Housing interventions that involve group homes have been found to support the recovery of persons with mental illness and those with addiction issues. The current study explored the views of homeowners in relation to a supportive housing program called Community Homes for Opportunity (CHO) that modernised a provincial group home program (Homes for Special Care [HSC]) and provided recommendations for improving the program implementation in other geographical areas of Ontario. METHODS: We applied ethnographic qualitative techniques to purposefully recruit 36 homeowner participants from 28 group homes in Southwest Ontario, Ontario Canada. Focus group discussions were conducted at two time points, during CHO program implementation (Fall 2018, and post implementation phases (Winter 2019) respectively. RESULTS: Data analysis yielded 5 major themes. These include: (1) general impressions about the modernization process, (2) perceived social, economic and health outcomes, (3) enablers of the modernization program, (4) challenges to implementation of the modernization program, and (5) suggestions for implementation of the CHO in future. CONCLUSIONS: A more effective and expanded CHO program will need the effective collaboration of all stakeholders including homeowners for successful implementation.

Evaluation of New York/New York III permanent supportive housing program.

In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007-2017) from the NY/NY III evaluation team, to analyze this program's impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.

Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review.

Cognitive impairment is common amongst people experiencing homelessness, yet cognitive screening and the collection of history of brain injury rarely features in homelessness service delivery practice. The purpose of this research was to scope and map strategies for screening for the potential presence of cognitive impairment or brain injury amongst people experiencing homelessness and identify instruments that could be administered by homelessness service staff to facilitate referral for formal diagnosis and appropriate support. A search was conducted across five databases, followed by a hand search from relevant systematic reviews. A total of 108 publications were included for analysis. Described in the literature were 151 instruments for measuring cognitive function and 8 instruments screening for history of brain injury. Tools that were described in more than two publications, screening for the potential presence of cognitive impairment or history of brain injury, were included for analysis. Of those regularly described, only three instruments measuring cognitive function and three measuring history of brain injury (all of which focused on traumatic brain injury (TBI)) may be administered by non-specialist assessors. The Trail Making Test (TMT) and the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are both potentially viable tools for supporting the identification of a likely cognitive impairment or TBI history in the homelessness service context. Further population-specific research and implementation science research is required to maximise the potential for practice application success.