CRICH scientist_ Vicky Stergiopoulos's presentation on the 'Mental by dfsdf224s


									      MHCC Research Demonstration
    on Mental Health and Homelessness:
            Toronto Proposal

        Vicky Stergiopoulos, MD, MHSc, FRCPC
      Medical Director, Inner City Health Associates
Research Scientist, Centre for Research on Inner City Health
                   St. Michael’s Hospital
      Today’s presentation
Project Overview
  Housing and Support Services
Toronto proposal
  Progress to date
  Unique features
Project governance
Next steps
Growing numbers of homeless across
High prevalence of mental illness, substance
use and chronic physical conditions.
Many different subgroups with different
needs, e.g. youth, seniors, immigrants,
indigenous people.
Chronically homeless have highest level of
need and account for largest proportion of
service and societal costs.
               True or False?

"... most homeless choose that condition because of drug
or alcohol abuse or mental impairment."
The Toronto Street Needs Assessment
revealed that 9/10 homeless clients
interviewed in Toronto would like to be

                           City of Toronto, 2006
           True or False?

  A homeless person with a mental
illness has little chance of recovery.
 Treatment and housing placement of
homeless mentally ill individuals has been
associated with:
   Reductions in psychiatric hospitalizations
   Decreased psychiatric symptoms and
  substance use
   Improved neuropsychological functioning
   Lower healthcare costs

                                      Steidman, 2002
                                      Dickey, 2000
MHCC Research Demonstration
Supported by funding agreement between the MHCC
and Health Canada.

Multi-site, four year demonstration projects in
Vancouver, Winnipeg, Toronto, Montreal and

Randomized controlled trials “to provide policy
relevant evidence about what service and system
interventions best achieve housing stability and
improve health and well being for those who are
homeless and mentally ill”.
MHCC Research Demonstration Projects
      Additional Objectives
 Effective approaches to integrating housing
supports and the basket of necessary
Development of best practices and Lessons
Identification of unique problems and
solutions for diverse ethno-cultural groups.
Legacy of improved system integration and
Enhanced service and evaluation capacity.
MHCC Research Demonstration Projects
     Housing First Philosophy
Housing First creates a recovery oriented
culture that puts consumer/tenant choice at
the centre of all its considerations.

Rent supplements are provided so that
participants pay 30% or less of their income
for housing.
MHCC Research Demonstration Projects
       Housing First Model
  Housing in self-contained units, mostly private
  sector and scattered site, with a $600/month rental

  Treatment and support services are voluntary,
  individualized, culturally appropriate and are
  based off site.

  No conditions on housing readiness.

  Tenancy is not tied to engagement in treatment.

  Requirements: rent paid directly to the landlord,
  once a week visits by follow-up supports for pre-
  determined period.
MHCC Research Demonstration Project
     The Study Participants
   18 years or older.
   Is homeless or precariously housed with
   a history of absolute homelessness in the
   past year.
   Has a serious mental illness, but does not
   require formal diagnosis at time of
Eligible clients will be randomized to the
study interventions or care as usual.
MHCC Research Demonstration Project
        The Interventions
       High Needs Group
Recovery Oriented Assertive Community
Treatment (Pathways Model).
Client/staff ratio of 10:1 or less and includes
psychiatrist, nurse.
Program staff are closely involved in hospital
admissions and discharges.
Teams meet daily and include at least one
peer specialist as staff.
Seven day a week, 24 hr crisis coverage.
MHCC Research Demonstration Project
        The Interventions
     Moderate Needs Group
Intensive case management for a minimum of
one year once housed (Streets to Homes
Client/staff ratio of 20:1 or less.
Integrated efforts across multiple workers and
agencies possible.
Centralized assignment and monthly case
Seven day a week, 12 hours per day
MHCC Research Demonstration Projects
       Treatment as usual
Homeless individuals will be eligible to
access the array of local services and
Will not receive any of the service
interventions funded by the MHCC.
Can receive similar services as available.
MHCC Research Demonstration Project
          The Research
 A pragmatic, multi-site field trial of the
effectiveness and costs of a complex
community intervention using mixed methods.

Evaluation dimensions:
  Formative Evaluation
  Process Evaluation
  Impact Evaluation
  Linked Studies
MHCC Research Demonstration Project
          The Research
Data will be collected at baseline and then every six
months for the following two years.
  Domains of interest include: housing; health
  status; substance use; quality of life; functioning;
  healthcare system use and costs; justice system
  use and costs.

Will be supplemented by four qualitative research
reports on the following:
    the planning and proposal development phase.
    the personal stories of consumers at baseline.
    the implementation of the intervention.
    the personal stories of consumers at the 18-
   month follow-up.
The Toronto Proposal
           Toronto Proposal
Toronto Street Needs Assessment: a minimum of
5,052 homeless on April 19, 2006:

  72% in shelters
  16% outdoors
  5% in hospitals and treatment facilities
  3% in correctional facilities
  3% in assaulted women’s shelters

Over 30,000 shelter users per year.
Toronto population poses unique challenges, given
its cultural diversity.
           Toronto Proposal
              The Leads
Collaborative proposal development.
Research Coordinator: Centre for Research on
Inner City Health, St. Michael’s Hospital.
Service Coordinator: Shelter Support and Housing
Administration Division, City of Toronto.
Broad and meaningful community participation, in line
with core principles of equitable decision-making.
Proposal submitted on January 30, 2009:
             Toronto Proposal
               Sample Size
Five Groups to be recruited- 560 people in total.

   200 people assessed to have high needs
      100 to receive ACT, 100 to receive usual care

   360 people assessed to have moderate needs
      100 to receive ICM, 100 to receive ethno-specific ICM,
      160 to receive usual care

   320 people from immigrant and ethno-racial
          Toronto Proposal
         Recruitment Strategy
Multiple points of entry, including:
   Shelters -75%
   Streets - 17%
   Health Care Facilities – 6%
   Post incarceration – 3%
Referrals from a continuum of service providers.
Research coordinator mobile in the community to
meet with clients.
Intake with service provider within 5 business days.
           Toronto Proposal
           Housing Strategies
Support offered by the City or its agent

Offer a menu of housing options

Support to bring on individual housing units

Administrate payments to landlords

Assist with last month’s rent

Budget for furnishings
         Toronto Proposal
     Unique Research Elements
Physical Health
  Facilitated access to primary care for all study
  Primary care utilization, access to preventive care,
  selected physiological measures.

Third Arm
   Ethno-specific ICM, using Housing First principles.
   Collaborative development of model of care.
   Does it work? How does it work? For whom does
   it work?
        Toronto Proposal
      Knowledge Translation
A variety of knowledge dissemination tools
will be used, including:
  Web-based networking site
  Sector outreach initiatives
  Regular Project Town Hall meetings
  Annual MHCC Learning Symposium
  Project Newsletter
  Additional communication media
          Toronto Proposal
Site Operations Team
  People with Lived Experience Caucus?

Toronto Advisory Committee

National Advisory Committee
  Consumer Advisory Committee

Site Coordinator
       Toronto Proposal
  People with Lived Experience
The knowledge of Persons With Lived Experience
(PWLE) will directly inform:
  service implementation.
  equitable representation of PWLE in the oversight
  and governance of this project.
  development of local research questions and local
  methods for gathering and interpreting data.
  approaches for informing local and national
  stakeholder communities.
  approaches for sustaining the interventions after
  the research project is over.
         Toronto Proposal
            Next Steps
Revise / resubmit proposal (End of March?)
If successful, submit to the SMH Research
Ethics Board for approval (April-August)
Establish Site Operations Team (April)
Establish Local Advisory Committee (April-
Hire and train service and research staff,
recruit landlords (April-August)
Begin Recruitment (September).

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