The Chez Soi trial of Housing First in Montreal: Results and implications of a natural experiment at 4 years

Transcription

1 The Chez Soi trial of Housing First in Montreal: Results and implications of a natural experiment at 4 years Eric Latimer, Ph.D. Research Scientist, Douglas Mental Health University Institute Professor, Department of Psychiatry, McGill University, Montreal, Canada Canadian Association for Health Services and Policy Research Toronto, May

2 Co-authors Zhirong Cao, M.Sc. Erika Braithwaite, Ph.D. candidate Daniel Rabouin, M.Sc. Christopher McAll, Ph.D. Christian Méthot, M.Sc. Angela Ly, B.Com, MHA

3 At Home / Chez Soi funding and project team Funding from Health Canada via Mental Health Commission of Canada (MHCC) MHCC: Cameron Keller, ( ); Jayne Barker ( ) MHCC: Catharine Hume, Director, Housing and Homelessness ( ) Paula Goering, Ph.D., Center for Addictions and Mental Health and University of Toronto, National Research Lead Approximately 40 investigators from across Canada 5 site coordinators, research coordinators and numerous research staff, persons with lived experience, service and housing providers. Eric Latimer was lead investigator for the Montreal site and lead economist on the national research team. Other investigators on Montreal extension study: Anne Crocker, Henri Dorvil, Erica Moodie, Laurence Roy, Catherine Vallée Carol Adair, Geoff Nelson, Scott Veldhuizen (national research team) also contributed in important ways to the content Opinions expressed are those of the presenter and may not reflect those of Health Canada or the MHCC

4 What is Housing First?

5 Predominant continuum of care model Outreach Shelter Comply? Y Transitional Housing Comply? Y Permanent Housing N N + poorly integrated care Shelter Community center Health care / 5

6 Housing First At Its Simplest : Immediate Access To Permanent Housing Without Prior Sobriety Or Other Conditions Outreach, intake, assessment Permanent Housing with Supports / 6

7 / 7 Housing First, Pathways to Housing version : Philosophy & Program Model Immediate access to housing no sobriety or other preconditions Usually subsidized, scattered-site, private market apartments Housing and support functions are managed separately but work together for the client Help clients in pursuit of their own goals emphasis on client choice, respecting dignity of client Harm reduction, collaborative approach in dealing with substance abuse Pro-active in seeking to engage help-avoiding clients Fidelity scale now available Sam Tsemberis

8 The AHCS study ( )

9 Five Sites : Vancouver, Winnipeg, Toronto, Montréal & Moncton

10 Eligibility and need level criteria Eligibility requires : Current absolute homelessness OR precariously housed + absolute homelessness in past year (2 episodes or 1 of 4 weeks or more) AND No current ACT/ICM services AND 1 of 6 current diagnoses (psychotic disorder, mania or hypomania, mood disorder w/ psychotic features, major depression, PTSD, panic disorder) High need requires (others moderate need): Multnomah Community Ablity Scale score of 62 or less AND Current psychotic or (mania or hypomania) or mood disorder w/psychotic features / 10 AND 2 hospitalization for mental illness in 1 of last 5 years, OR recent arrest/incarceration, OR comorbid substance use

11 Recruitment and randomization by need level in Montreal No / 11

12 Nature of common (core) interventions Housing First: Almost exclusively subsidized apartments chosen by participants with support of housing specialists Care delivered by Assertive Community Treatment (ACT) or Intensive Case Management (ICM) teams according to participant need level Treatment-as-usual A few participants served by ACT or ICM teams For the great majority, disconnected array of shelters, subsidized congregate housing (limited availability), hospital-based outpatient and / 12 inpatient care, etc.

13 Simon, Montréal HF participant, visiting his first apartment

14 Valère Rioux, Montréal control group participant

15 Members of the Montréal CSSS JM ICM team

16 Dr Marie-Carmen Plante, Montréal ACT team psychiatrist, and a participant

17 Valéry, landlord, a partner of the Montréal Chez Soi project

18 Key domains covered by questionnaires Baseline Every 3 months Every 6 months Final (21 or 24 months) Demographics Housing, voc, service use Hx Physical comorbidities Residential, vocational TLFB x x x Mental health and SA (CSI, GAIN) x x x QOL (SF6D, EQ5D, QoLI 20 and social support) / 18 X X X x x x Recovery x x Community funct., MCAS x x x Health, social, justice service use x x Working alliance x x Cognitive impairment x x

19 Qualitative interviews 10% representative (almost random) sample of all experimental groups Qualitative interviews shortly after baseline and about 18 months later / 19

20 Key results of AHCS in Montreal

21 Excellent Follow-Up Rates in Montréal during ACHS Group Originally randomized Final interviews completed Follow-up rate (Oct 09 May 11) (Oct 11 Mar 13) HN - ACT % HN TAU % MN JM % MN DIOG % MN TAU % / 21 Total %

22 Key findings at 2 years (excluding economic)

23 Pourcentage Montreal: Time Spent Stably Housed, in Shelters And on The Street 100% 90% 80% 70% Besoins élevés Besoins modérés 60% 50% 40% 30% 20% 10% 0% 21/24 mo 18 mo 15 mo 12 mo 9 mo 6 mo 3 mo 0 mo - 3 mo 21/24 mo 18 mo 15 mo 12 mo 9 mo 6 mo 3 mo 0 mo - 3 mo / 23 Logement Son appartement stable (HF) (HF) Logement Son appartement stable (TAU) (TAU) Refuge (HF) Refuge (TAU) Rue (HF) Rue (TAU)

24 Montréal: Improvement in Functioning (MCAS) among MN Participants... MCAS: Besoins modérés IC 95% p<0.03 T0 6m 12m 18m 21m/24m Temps Traitement habituel Groupe expérimental

25 and HN as well MCAS: Besoins élevés IC 95% p < 0.02 T0 6m 12m 18m 21m/24m Temps Traitement habituel Groupe expérimental

26 Improvement in quality-of-life (Lehman QoLI-20) among MN participants QOLI-20: Besoins modérés IC 95% p < T0 6m 12m 18m 21m/24m Temps Traitement habituel Groupe expérimental

27 but not among HN participants QOLI-20: Besoins élevés IC 95% No statistically significant difference T0 6m 12m 18m 21m/24m Temps Traitement habituel Groupe expérimental

28 Qualitative interviews: More positive trajectories among MN participants TAU HF High Needs High Needs I J K L M N O P A B C D E F G H Moderate Needs Moderate Needs AI AJ AK AL AM AN AO AP AQ AR 0-10 Q R S T U V W X Y Z AA AB AC AD AE AF AE AG AH Positive trajectory overall -20 Negative trajectory overall

29 Immediate aftermath of AHCS in Montreal

30 End of AHCS funding: Québec Government response April : RHA collapses CSSS JM ACT and ICM teams into one small team (16 to about 4 staff), Diogène team reduced from 4 to 2 Housing team at Douglas maintained Common mission: transition all participants to usual services BUT Diogène resists! Diogène succeeds in convincing RHA to let it follow 50 (mostly among more disabled) participants, gradually increase staff New name: Un toit d abord Some other participants end up transferring to Diogène

31 Partial success on rent supplements December 2013: Government allows 131 rent supplements for participants who are still housed RHA sets up small new housing team

32 Consequences for situations of participants About 50 participants stayed with Diogène, mostly maintaining rent supplements About 80 other participants kept rent supplements, a few transferred to Diogène, most to a variety of usual services The rest, about 150 participants, back in usual services

33 Extension study Similar follow-up interviews (quant & qual) about 4 to 4 ½ years post-randomization (Feb 14 Oct 15)

34 Good Follow-Up Rates with minimal differential attrition Group Originally randomized Final interviews completed Follow-up rate (Oct 09 May 11) (Feb 14 Oct 15) HN - ACT % HN TAU % MN JM % MN DIOG % MN TAU % / 34 Total %

35 Percentage (%) Time Spent Stably Housed, in Shelters And on The Street High Needs Moderate Needs Own apartment (HF - JM) Own apartment (TAU) Own apartment (Diogène) Shelter (HF - JM) Shelter (TAU) Shelter (Diogène) Street (HF - JM) Street (TAU) Street (Diogène) / 35

36 QoL and Functioning No difference between groups on either measure at 4-year follow-up, for either HN or MN all gains appear to have dissipated! / 36

37 Qualitative interviews Analysis of 22/50 interviews so far suggests: o Continuing improvement for those who were responding well to HF and have continued to receive it (2 people) o Some gains appear maintained for MN participants transitioned to usual services o A few TAU participants find good support services within the usual system o The relative freedom combined with support that HF offers appears to strike the right balance for many / 37

38 (Preliminary) Conclusions Transition to usual services for HN group appears unambiguously deleterious gains seem largely lost More ambiguous situation for MN : o Some gains may be maintained following loss of services / 38

39 (Preliminary) Implications Services for high-need participants need to be maintained for several years at least Such programs need to be funded provincially Possible that some moderate-need HF participants can be transitioned successfully to usual services after 2-3 years Federal HPS program orientation towards expecting all MN participants to transition to usual services within 3 years may be unrealistic / 39

40 Thank you for your attention / 40