Reflections on Lessons Learned from a Housing First Researcher Tim Aubry, Ph.D., C.Psych. Third Research Symposium Calgary, Alberta April 23, 2015

#1 Housing First is Equally Effective in Cities of Different Sizes and Composition Across Canada. Vancouver Pop: 578, 000 Winnipeg Pop: 633, 000 Toronto Pop: 2,503,000 Montreal Pop: 1,621,000 Moncton Pop: 107,000

#2 People with Severe Addictions Can Also Achieve Housing Stability with Housing First. Percentage of Time Spent in Housing in the Past Year

#3 It is Virtually Impossible to Predict Who Will Not Be Successful in Housing First Programs.

Community- based, Residential Treatment (on-site clinical staff) Permanent Single Site (on-site services) Permanent housing (scatter-site, off site services) Redesigning the System: Housing First Approach Longer term Institutional Care Least Restrictive Setting Most Restrictive Setting

#4 Housing First Programs Achieve Only Modest Non-Housing Outcomes. Differences in Quality of Life Differences in Community Functioning

/ 9 Logic Model of Housing First Housing First Housing First Engagement + Stable Housing + Health and Social Services Engagement + Stable Housing + Health and Social Services Recovery = Functioning + Community Integration + Quality of Life Recovery = Functioning + Community Integration + Quality of Life

#5 There is No Evidence That Housing First Impacts Employment, Vocational, or Educational Outcomes. Housing First 25% Treatment as Usual 28% % of Participants with Moderate Needs Obtaining Some Form of Employment

#6 Housing First is a Modest Investment with Modest Cost Offsets.

/ 12 Cost Analysis – Based on Service Use (Top 10% Users) $10 investe d in Housing for Top Decile (TD) group : Average savings of $21.72 #6 Housing First is a Modest Investment with Modest Cost Offsets.

/ 13 Cost Analysis – based on Service use (High Users) Major cost offsets are hospitals, home visits, jail/prison office visits #6 Housing First is a Modest Investment with Modest Cost Offsets.

fidelity adaptation #7 Programs Must Stay True to Core Housing First Standards to Achieve the Best Outcomes. Maintaining a Balance between Fidelity and Adaptation

fidelity adaptation “When Fidelity Goes Out the Window” #7 Programs Must Stay True to Core Housing First Standards to Achieve the Best Outcomes.

/ 16 Fidelity Standards for Housing First Approach Fidelity Domains Description Housing Choice and Structure Standards focusing on the provision of housing to consumers (e.g., housing choice, housing availability, integrated housing) Separation of Housing and Services Standards focusing on the relationship between housing and support provided by program (e.g., no housing readiness, standard tenant agreement, commitment to re-house) Service Philosophy Standards focusing on the principles and values guiding the delivery of services (e.g., service choice, harm reduction, assertive engagement, person- centered planning) Service Array Standards focusing on range of services available to consumers (e.g., psychiatric services, integrated substance abuse treatment, nursing services, supported employment services) Program Structure Standards focusing on service delivery characteristics (e.g., frequency of contact with participants, participant / staff ratio, team approach, peer specialist on staff)

/ 17 Consumer Narrative Sub-Sample (N = 195) Positive life change – “This is the first time, you know, that I’ve had a home… like I’ve had supportive housing before, but I didn’t feel like I was safe. And, this is the first place like I… feel like I love to go home…I feel so safe. Mixed/neutral life change – “That’s what life is, cause it’s just like I said, like picking up, losing it all, picking up, losing it all, picking up, losing it all.” Negative life change – “They discharged me to a hotel. I left the next day. It was noisy, bug-infested, full of drugs.” #8 Qualitative Findings of Housing First Studies are More Impressive than Quantitative Findings.

Participant Feedback about Life Course

#9 Landlords Who Partner with Housing First Programs Are Business People with Prosocial Motives.

/ 20 #9 Landlords who Partner with Housing First Programs are Business People with Prosocial Motives.

#10 Social Isolation and Poverty are Ongoing Challenges Faced by Many Successful Tenants in Housing First Programs. “Housing is First. What’s next?”

Future Directions 1. Achieving recovery outcomes 2. Integrating addictions treatment into HF 3. Improving employment outcomes 4.Adopting a strengths-based approach 5. Adapting HF for youth & families 6.Accommodating people with additional needs who are not succeeding in HF

Acknowledgements The national At Home/Chez Soi project team: Jayne Barker, PHD ( ) and Cameron Keller, MHCC National Project Leads; Paula Goering, RN, PhD, Research Lead and over 50 investigators from across Canada and the US. In addition there are 5 site coordinators and numerous service and housing providers as well as persons with lived experience. The research has been made possible through a financial contribution from Health Canada to the Mental Health Commission of CanadaThe views expressed herein solely represent the authors. The Supportive Housing Addictions Recovery Program – Evaluation was funded through a contract with the Ottawa Branch of the Canadian Mental Health Association. The evaluation team gratefully acknowledges the assistance and participation of the staff and clients of the Ottawa Supportive Housing for People with Problematic Substance Use program for their involvement in this evaluation. The evaluation team also thanks managers of CMHA Ottawa and the Oasis program for technical support in conducting of the evaluation. We also thank the Mental Health Commission of Canada for providing the research protocol of the At Home / Chez soi Demonstration Project.

Thank You! Questions?