Vancouver At Home: pragmatic randomized trials investigating Housing First for homeless and mentally ill adults

Abstract

BackgroundIndividuals with mental illnesses are overrepresented among the homeless. Housing First (HF) has been shown to promote positive outcomes in this population. However, key questions remain unresolved, including: how to match support services to client needs, the benefits of housing in scattered sites versus single congregate building, and the effectiveness of HF with individuals actively using substances. The present study aimed to recruit two samples of homeless mentally ill participants who differed in the complexity of their needs. Study details, including recruitment, randomization, and follow-up, are presented.MethodsEligibility was based on homeless status and current mental disorder. Participants were classified as either moderate needs (MN) or high needs (HN). Those with MN were randomized to HF with Intensive Case Management (HF-ICM) or usual care. Those with HN were randomized to HF with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care. Participants were interviewed every 3 months for 2 years. Separate consent was sought to access administrative data.ResultsParticipants met eligibility for either MN (n = 200) or HN (n = 297) and were randomized accordingly. Both samples were primarily male and white. Compared to participants designated MN, HN participants had higher rates of hospitalization for psychiatric reasons prior to randomization, were younger at the time of recruitment, younger when first homeless, more likely to meet criteria for substance dependence, and less likely to have completed high school. Across all study arms, between 92% and 100% of participants were followed over 24 months post-randomization. Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data.ConclusionThe study successfully recruited participants meeting criteria for homelessness and current mental disorder. Both MN and HN groups had high rates of substance dependence, suicidality, and physical illness. Randomization resulted in no meaningful detectable differences between study arms.Trial registrationCurrent Controlled Trials: ISRCTN57595077 (Vancouver at Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing First plus Intensive Case Management versus treatment as usual).

Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes

“…Significant differences in HQ between groups in Vancouver are likely attributable to the concentration of very low quality accommodations in the city's urban core, where homelessness is most visible. 24,25 After adjustment for other important variables, site was a significant predictor of HQ only for Winnipeg. There are important contextual differences with this city that can explain these findings.…”

Are Substance Use and Mental Illness Associated to an Earlier Onset of Homelessness?

“…From using the data from a large Canadian longitudinal research trial, the At Home/Chez Soi Project, possible associations will be evaluated in this study. The At Home/Chez Soi Project (2009-2013) was conceived to investigate the efficacy of the Housing First model in five Canadian urban settings [32,33]. To date, Housing First is considered (confirmed by the At Home/Chez Soi results [34], to be the best available approach to homelessness [35].…”

“…It is important to note that the inclusion criterion for the At Home study was that all participants had a mental disorder, diagnosed with an appropriate instrument. The design of the At Home study has been described in depth in other papers [32,33].…”

“…The At Home/Chez Soi Study was a four-year national randomized clinical trial investigating interventions designed to test the effectiveness of Housing First with different psychosocial stabilization methods for the homelessness with mental disorders over a two year follow-up period across five cities in Canada: Vancouver, Winnipeg, Montreal, Moncton and Toronto [32,33]. In this analysis, only data from the Vancouver site was considered.…”

Randomised controlled trial of GP-led in-hospital management of homeless people (‘Pathway’)

“…Primary care physicians have the skills to address these issues. 6 A number of studies have examined housing interventions (such as Housing First) in homeless people with mental health disorders and HIV, [7][8][9][10][11] but studies in those with medical disorders have not been reported. In 2010, a GP-led and nurse-led intervention involving a hospital 'in reach' team for homeless people at University College Hospital London was developed.…”