Presentation given by Tim Aubry and Geoffrey Nelson, CAN at the Ninth European Research Conference on Homelessness, "Homelessness in Times of Crisis", Warsaw, September 2014 http://feantsaresearch.org/spip.php?article222&lang=en

1. Outcome Findings of Canada’s At Home / Chez Soi Housing First Demonstration Program
Tim Aubry, National Research Team, At Home/Chez Soi Project, School of Psychology, University of Ottawa, Ottawa, Ontario, Canada Geoffrey Nelson, National Research Team, At Home/Chez Soi Project, Dept. of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada 9th European Research Conference – Homelessness in Times of Crisis, FEANTSA, Warsaw, Friday, September 19, 2014

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Overview of Presentation
1.Study design
2.Description of Housing First Interventions
3.Characteristics of participants
4.Outcome findings
5.Costing findings
6.People with additonal needs

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Study Design
Pragmatic, multi-site, randomized, mixed methods field trial in five sites across Canada (Vancouver, Winnipeg, Toronto, Montreal, & Moncton)
Investigation of effectiveness and cost-effectiveness of Housing First in Canadian contexts
Model being tested with support at two levels of intensity (high needs = ACT) (moderate needs = ICM) vs. usual care

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At Home/Chez Soi Housing First Approach
+
Subsidized Housing
Support
(ACT or ICM)

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Characteristics of Housing
• No pre-conditions for housing
• Scattered site private market units
• Maximum of 30% of income for rent
• Participants hold their own lease
• Rights and responsibilities as a tenant

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Types of Support Services
Assertive Community Treatment (ACT): ACT
•Multi-disciplinary team / wrap around service
•Services and crisis coverage are available 24/7
•Staff to client ratio of 1:10
Intensive Case Management teams (ICM):
•Case managers with individual caseloads
•Outreach and coordination with other services
•Teams available 12 hours per day
•Staff to client ratio of 1:15

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Who is in At Home/Chez Soi?
•2148 participants
•1158 in Housing First (HF)
•990 in Treatment as Usual (TAU)
•Primarily middle-aged
•32% of participants are women
•22% of participants identified as being an Aboriginal person
•Typical total time homeless in participants’ lifetimes is nearly 5 years
•All have one or more serious mental health issue
•Majority have a concurrent disorder
•More than 90% had at least one chronic physical health problem

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Housing Outcomes of participants
Close to 1,000 Canadians with significant histories of homelessness were successfully housed through At Home / Chez Soi
0%
10%
20%
30%
40%
50%
60%
70%
Housed all of the time
Housed some of the time
Housed none of the time
Percentage of participants housed in the last six months of the study
Housing First
TAU

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Housing: Stability – by Program
Percentage of time housed

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Housing: Stability – by Site
Percentage of time housed

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Social Outcome Findings
HF participants in both ICM and ACT reported greater improvements than TAU participants in:
Community Functioning
Quality of Life

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Social Outcomes: Community Functioning
Average post BL differences are SIG
for both ICM and ACT

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Social Outcomes: Quality of Life
Average post BL differences are SIG
for both ICM and ACT

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Health Outcome Findings
•Both groups report improvements in:
Substance use
Mental health
•Both groups maintained their physical health

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HN average intervention cost nationally: $22,257 per person per year
$10 invested in HF for High Need group : Average savings of $9.60
Cost Analysis – High Need Group (ACT)
$-
$15.000
$30.000
$45.000
$60.000
$75.000
$90.000
TAU
Housing First
TAU
Housing First
Baseline
0M to 21/24M
HF

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HN Group: Major cost offsets are office visits, hospitals, shelters, visits with other providers and jail or prison
Cost Analysis – High Need Group (ACT)
$(5.000)
$(4.000)
$(3.000)
$(2.000)
$(1.000)
$0
Office visits (non- study)
Hospital (Physical)
Emergency shelter
Home visits (non- study)
Jail/prison

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$10 invested in HF for Moderate-Need group : Average savings of $3.42
MN average intervention cost nationally: $14,177 per person per year
Cost Analysis – Moderate Need Group (ICM)
- $
10.000 $
20.000 $
30.000 $
40.000 $
50.000 $
60.000 $
TAU
Housing First
TAU
Housing First
Baseline
0M to 21/24M
HF

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MN Group: Major cost offsets are shelters and SROs, but costs related to office visits to non study providers increase
Cost Analysis- Moderate Need Group (ICM)
$(2.500)
$(2.000)
$(1.500)
$(1.000)
$(500)
$0
$500
$1.000
$1.500
Emergency shelter
SRO (w support)
Office visits (non-study)

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Cost Analysis – based on Service use (High Users)
- $
50.000 $
100.000 $
150.000 $
200.000 $
250.000 $
TD-TAU
TD-HF
TD-TAU
TD-HF
Baseline
0M to 21/24M
HF
$10 invested in HF for TOP DECILE group : Average savings of $21.72
TD – Top Decile

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Cost Analysis – based on Service use (High Users)
$(20.000)
$(15.000)
$(10.000)
$(5.000)
$0
$5.000
Hospital (Psychiatric)
Home visits (non-study)
Jail/prison
Office visits (non-study)
Hospital (Physical)
Contacts with the police
ER Visits
Crisis housing
SRO (w support)
Psychiatric residential program
Major cost offsets are hospitals, home visits, jail/prison office visits

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Cost Analysis
Overall Cost Analysis
•Housing First costs $17,735 per person per year on average
•Over the 2-year period following participant enrolment HF services resulted in average reductions of $12,073 in service costs per person.
•Thus every $10 invested in HF services saved an average of $6.81.
•The main cost offsets included: hospital (psychiatric), emergency shelter, hospital (physical) and office visits (non-study)
Cost Analysis based on High Service Users
•Among the 10% who prior to study entry had been using the most services, savings are even more dramatic. This group includes both moderate and high need participants (ICM and ACT)
•The intervention cost $19,582 per person per year on average. Over the 2- year period following participant enrolment every $10 invested in HF saved an average of $21.72.

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People with Additional Needs
•HF worked well for clients with diverse ethnocultural backgrounds and circumstances. However for a small group of participants (about 13%) from whom HF as currently delivered did not result in stable housing in the first year.
•This group tends to have longer histories of homelessness, lower educational levels, more connection to street-based social networks, more serious mental health conditions.
•However, these variables although significant were not strong predictors of encountering housing difficulties in the first year.
•Alternative approaches to addressing the unique needs of these clients were tried in some cities.

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Consumer Narrative Sub-sample
Narrative sub-sample comparable to the full sample
• N=197 at 18-months, 10% of the total sample
•No significant differences on more than 50 variables for full and sub-samples
•Participants interviewed at baseline and 18-months
•10% attrition rate over time, N=219 at baseline
•13 life domains re: changes – e.g., typical day, education, work, housing
•Each interview coded for life changes – positive, mixed/neutral, negative (Kappa=.77 for inter-rater reliability)

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Consumer Narrative Sub-sample
Coding example
• Positive life change – “This is the first time, you know, that I’ve had a home… that I actually feel, 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. And…being safe is a major issue for me, you know?”
• 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.”

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Positive, Mixed/neutral, and Negative Life Changes by Site and by Treatment Condition
Site
HF – Type of Change
TAU – Type of Change
Positive
Mixed/neutral
Negative
Positive
Mixed/neutral
Negative
Moncton
6 (75.0%)
2 (25.0%)
0 (0%)
1 (12.5%)
3 (37.5%)
4 (50.0%)
Montreal
19 (70.3%)
2 (7.4%)
6 (22.3%)
5 (27.7%)
1 (5.6%)
12 (66.7%)
Toronto
15 (71.4%)
3 (14.3%)
3 (14.3%)
6 (50.0%)
2 (16.7%)
4 (33.3%)
Vancouver
12 (48.0%)
12 (48.0%)
1 (4.0%)
6 (33.3%)
9 (50.0%)
3 (16.7%)
Winnipeg
15 (83%)
13 (17%)
0 (0%)
3 (20.0%)
10 (6.7%)
2 (13.3%)
All Sites
67 (61%)
32 (29%)
10 (10%)
21 (30%)
25 (35%)
25 (35%)
Mantel Haenszel χ2=28.5, df=1, p=.0000001

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Summary of Key Findings
1.Housing First is doable in Canadian cities
2.Fidelity to a Housing First model is essential
3.Housing First can rapidly end homeless
4.Housing First produces other positive outcomes
5.Housing First makes good use of public dollars
6.A small minority of individuals present with additional needs and fail to settle in HF

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Acknowledgements
This presentation: Carol Adair, David Streiner, Brianna Kopp, Scott Veldhuizen, Eric Latimer, Paula Goering
The national At Home/Chez Soi project team: Jayne Barker, PhD, (2008-11), Cameron Keller (2011-14), and Catharine Hume (2014-present) MHCC National Project Leads; Paula Goering, RN, PhD, Research Lead, and approximately 40 investigators from across Canada and the US. In addition there were 5 site coordinators and numerous service and housing providers as well as persons with lived experience.
This research has been made possible through a financial contribution from Health Canada to the Mental Health Commission of Canada. The views expressed herein solely represent the authors.

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At Home/Chez Soi: National Research Team
•Paula Goering, CAMH, University of Toronto, Research Lead
•Carol Adair, University of Calgary
•Tim Aubry, University of Ottawa
•Jeffrey Hoch, St. Michael’s Hospital, University of Toronto, University of Western Ontario
•Geoff Nelson, Wilfrid Laurier University
•Myra Piat, Douglas Mental Health University Institute; McGill University
•David Streiner, Baycrest Hospital; University of Toronto
•Sam Tsemberis, Pathways to Housing, Inc

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At Home/Chez Soi Local Leads
Moncton: Tim Aubry, University of Ottawa; & Jimmy Bourque, Université de Moncton Toronto: Stephen Hwang, St. Michael’s Hospital, University of Toronto; Vicki Stergiopoulos, St. Michael’s Hospital, University of Toronto; & Pat O’Campo, St. Michael’s Hospital, University of Toronto Montreal: Eric Latimer, Institut Douglas, McGill University; & Christopher McAll, Université de Montréal Winnipeg: Jino Distastio, University of Winnipeg; & Jitender Sareen, University of Manitoba Vancouver: Julian Somers, Simon Fraser University; Michael Krausz, University of British Columbia; & Jim Frankish, University of British Columbia

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Visit: www.mentalhealthcommission.ca (for detailed information and reports) Visit: www.nfb.hereathome.ca (for video short stories about the project and our participants) Visit: www.housingfirsttoolkit.ca (for the Canadian Housing First Toolkit)
Questions?
Contact: gnelson@wlu.ca
or taubry@uottawa.ca