MHCC Research Demonstration Projects 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 Background Project Overview Housing and Support Services Research Toronto proposal Progress to date Unique features Project governance Next steps Background Growing numbers of homeless across Canada. 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." Fact The Toronto Street Needs Assessment revealed that 9/10 homeless clients interviewed in Toronto would like to be housed. City of Toronto, 2006 True or False? A homeless person with a mental illness has little chance of recovery. Fact 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 Projects Supported by funding agreement between the MHCC and Health Canada. Multi-site, four year demonstration projects in Vancouver, Winnipeg, Toronto, Montreal and Moncton. 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 services. Development of best practices and Lessons Learned. Identification of unique problems and solutions for diverse ethno-cultural groups. Legacy of improved system integration and support. 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 allowance. 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 Eligibility 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 referral. 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 Model). Client/staff ratio of 20:1 or less. Integrated efforts across multiple workers and agencies possible. Centralized assignment and monthly case conferences. Seven day a week, 12 hours per day coverage. MHCC Research Demonstration Projects Treatment as usual Homeless individuals will be eligible to access the array of local services and supports. 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 Background 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: http://torontomhccproject.ning.com 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 communities. 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 participants. 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 www.torontomhccproject.ning.com Sector outreach initiatives Regular Project Town Hall meetings Annual MHCC Learning Symposium Project Newsletter Additional communication media Toronto Proposal Governance 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- May) Hire and train service and research staff, recruit landlords (April-August) Begin Recruitment (September). ? ?