Reprinted from the "Housing" issue of Visions Journal, 2013, 8 (1), pp. 28-29
Homelessness has become a major social problem in many cities. People who are homeless experience serious health problems, as well as stigma, poverty and premature death. Life expectancy among homeless people is shortened by about 20 years in comparison to the general population.1
The Vancouver At Home study, which began in 2009, is investigating a recently developed approach known as Housing First to learn about the opportunities for recovery among people who have been chronically homeless and who have mental illness. Housing First provides people with immediate access to market housing, accompanied by health, social and vocational supports delivered by staff that visit the person’s home. Participants are expected to maintain contact with the support staff, but support workers respond to the goals and needs of the client. In practice, this means that clients decide whether (or when) they would like help addressing specific issues such as symptoms, substance use, community involvement, or employment.
A large network of collaborators have joined together to make this project happen, including universities, the City of Vancouver, various provincial ministries, service providers, not-for-profit societies, business and philanthropic organizations, and individuals and family members with direct experience of homelessness.
Looking at alternatives to ‘usual care’
Participants with different levels of need have been divided into groups. Some participants are receiving Housing First with visiting supports, while some participants have received housing in a single building with on-site supports. Each of these models of care was designed and implemented with project team members, with funding to allow their continued operations until March 31, 2013.
These models are being compared to the existing array of services and supports that are available in Vancouver (described as “usual care”). Prior to this study, no research had been conducted to find out how well “usual care” in Vancouver worked to support people who were homeless and mentally ill.
About 500 people were originally enrolled in the project. On average, participants were 41 years old, were first homeless at age 30, and nearly three quarters of the sample are male. All participants had some type of mental illness, most commonly a psychotic illness (52%) or depression (40%). Participants had been homeless for about five years of their lives. Those who had early life experiences of homelessness or who used illicit drugs had been homeless longer.3
Although the study didn’t seek out people with drug problems, the majority of participants met the formal criteria for substance dependence (58%) or were dependent on alcohol (24%). About one quarter of the participants were daily drug users (most commonly using marijuana), and our research discovered that these individuals had worse mental health symptoms than other participants.4
Concern was raised when we discovered that participants with more complex needs, such as substance use and mental illness combined, were less likely than others to receive necessary treatment.5 Integrating care for homeless people is a major challenge. The lack of accessible, effective treatment for people with complex needs may in part explain the premature mortality rate within this group.6
When presented with a choice of housing options, participants became residents in a wide variety of Vancouver neighbourhoods. In the vast majority of cases, they chose locations outside the Downtown region, in neighbourhoods that are not accessible to homeless people under current housing policies.
Results and recommendations to date
To date, participants have been followed for one year, with a follow-up rate of 90%. Results include the following:
The interventions are feasible to implement. New teams were created to deliver Housing First with community-based supports. Homes were secured throughout the city, and individuals who met criteria for chronic homelessness and mental illness were identified and linked with the housing and supports.
Participants became stable neighbours. In stark contrast to usual care, participants in Housing First had much higher rates of stable housing, indicating that they were successfully settling in to their new homes. They also used crisis services one third as often as those receiving usual care.
Participants became part of their communities. The majority of Housing First participants reported integrating into their new neighbourhoods and feeling like they belonged in their new communities. By contrast, people receiving usual care did not report feeling at home where they lived.
Quality of life improved. Participants in Housing First reported significant improvements in quality of life compared to those receiving usual care. Quality of life is related to improvements in health and social functioning.
Fewer emergency department visits. Participants in Housing First had significantly lower rates of emergency department visits than those in usual care. Participants in Housing First exhibited a decrease in ER visits to regional hospitals, while those in usual care saw their visits increase during one year of follow-up.
Crime decreased and public safety improved. The number of convictions among people in Housing First was less than half that of those in usual care during one year of follow-up.
Two overarching recommendations can be made based on lessons learned to date:
First, the interventions developed and introduced through Vancouver At Home produce significant benefits for participants, improve public safety and reduce the use of crisis and emergency resources. These models of care work better than the status quo, and they should be provided to all people whose needs match those of our participants.
Second, monitoring homelessness and rehousing in Vancouver should become business as usual. Prior to Vancouver At Home, no one was following the histories of people who are homeless in Vancouver. This meant there was no possibility of measuring waiting times or access to services, or of evaluating the effectiveness of what’s being offered. Investments in knowledge are essential if we are to successfully eliminate chronic homelessness.
About the author
Dr. Somers is a Clinical Psychologist and Associate Professor in the Faculty of Health Sciences at Simon Fraser University. He is interested in novel and innovative approaches to promote health and reduce drug-related harms in populations, particularly those that have been poorly served
Acknowledgement: The Vancouver At Home research is supported by a grant to Simon Fraser University, made possible through a financial contribution from Health Canada to the Mental Health Commission of Canada. The authors gratefully acknowledge the support of colleagues and collaborators in Winnipeg, Toronto, Montreal and Moncton
- Nielsen, S.F., Hjorthøj, C.R., Erlangsen, A. & Nordentoft, M. (2011). Psychiatric disorders and mortality among people in homeless shelters in Denmark: A nationwide register-based cohort study. The Lancet 377: 2205-14.
- Mental Health Commission of Canada, At Home/Chez Soi: www.mentalhealthcommission.ca/English/Pages/homelessness.aspx.
- Palepu, A., Patterson, M., Strehlau, V. et al. (In press). Daily substance use and mental health symptoms among a cohort of homeless adults in Vancouver, British Columbia. Journal of Urban Health.
- Patterson, M.L., Somers, J.M. & Moniruzzaman, A. (2012). Prolonged and persistent homelessness: Multivariable analyses in a cohort experiencing current homelessness and mental illness in Vancouver, British Columbia. Mental Health and Substance Use, 5(2), 85-101.
- Currie, L., Moniruzzaman, A. & Somers, J.M. (2010). Patterns and distribution of service use among adults experiencing homelessness and mental illness. Poster presented at International Conference on Urban Health, 27-29 October NY.
- Geddes, J. & Fazel, S. (2011). Extreme health inequalities: mortality in homeless people. The Lancet. 377: 2156-2157.