What we did: The Centre for Urban Health Solutions was responsible for leading the Toronto arm of the five-city At Home/Chez Soi randomized controlled trial of Housing First (HF).
About Housing First: The ‘At Home’ version of HF followed a model called ‘Pathways to Housing,’ originally developed in New York City. Key components include:
- Few pre-conditions. People are not required to seek treatment for mental health problems or addictions.
- Independent housing. People receive rent supplements, and are generally placed in independent, private market rental units.
- Housing that is separate from supports. HF supports are offsite – they are not tied to a building or unit. If people change their housing, supports will follow them.
For a step-by-step guide to implementing HF, visit: www.housingfirsttoolkit.ca
How we did it: At Home/Chez Soi was a randomized controlled trial of HF that took place in Toronto, Moncton, Montreal, Winnipeg and Vancouver from 2009 to 2011. To participate, people needed to have significant histories of absolute homelessness and a diagnosable mental health problem.
In Toronto, approximately 300 people were randomized to the intervention – in other words, they received HF as outlined above.* Another approximately 270 people were randomized to ‘Treatment as Usual’ – services already available in Toronto.
We are comparing outcomes such as mental health, quality of life and housing tenure (how long and how often people stayed housed) in these two groups over a four-year period.
In Toronto, people in the intervention arm received rent supplements of up to $600.00 a month. People with higher needs were assigned an Assertive Community Treatment Team. People with moderate needs were assigned a case manager.
What we learned:
What we learned about the At Home version of Housing First:
- After the first two years, evidence demonstrated that the At Home version of Housing First leads to housing stability for most people experiencing both homelessness and mental health problems. The At Home version of HF is an important program that should be resourced at a level that meets the need in Toronto.
- The At Home program doesn’t work for everyone. For example, in Toronto, in the last six months of the first phase of the study, 12 per cent of people who received the At Home program were not housed at all, and 16 per cent were only housed some of the time. Policy-makers must urgently focus on the delivery of high quality alternatives for this group in Toronto.
- Housing First programs should include carefully-considered and appropriate adaptations for different groups of people and different settings. See examples from Toronto and Winnipeg.
Detailed findings from the first two years of results in Toronto are available here.
Findings from all five cities involved in the At Home/Chez Trial are available here.
Lessons for policy-makers, funders and people responsible for HF programs:
We’ve compiled the findings from several scientific publications related to At Home/Chez Soi in Toronto to share key aspects of the HF model, adaptations applied in Toronto, and needed enhancements. You can download the full report here.
Key messages for policy-makers, funders and people responsible for HF programs include:
- Urgently address the crisis related to the shortage of quality, affordable housing in Toronto – this presented a significant barrier to implementation for the At Home program, as highlighted in a study examining barriers to implementation over time.
- Build safe, clean, interim housing options into the HF program – purpose built if necessary. These are essential for the wellbeing of people who are waiting for permanent housing, or to be re-housed.
- Once people are housed, address isolation through enhancements to the current program (e.g. additional peer support, life skills training, recreational and vocational opportunities).
- Invest in developing and maintaining relationships with landlords and working with people to maintain tenancies.
- Place a high priority on relationships between providers and participants, as strong, trusting alliances are associated with better outcomes.
- A commitment to anti-oppression/anti-racism is essential to program success and should include concrete measures. For example: hiring frontline and management staff representative of communities served.
Lessons for health and social services more generally
At the beginning of the trial, researchers analyzed interviews with people experiencing both homelessness and mental health problems in Moncton, Montreal, Toronto, Winnipeg and Vancouver. Their research revealed the following priorities for health and social services:
- Practical assistance like housing, financial assistance, phone, internet access, help finding employment and connections to social supports.
- Flexible, individualized services with a balance of medical, social, practical and cultural supports.
- Services that respond to people’s realities including evening/night hours, TTC tokens and/or mobile services.
- Access to talk therapy and peer groups including ongoing supports.
- Providers who relate to people as human beings, are compassionate and are able to ‘throw out the textbook’ when appropriate.
- Providers who ‘really get it’ due to personal experience with mental health problems, homelessness and/or ‘interlocking oppressions: such as those of race, class, gender, sexual, national and/or cultural identity.’
A summary of this paper is available here.
What’s next?
We will be following participants in both the intervention and Treatment as Usual arms at the Toronto site until 2016. We will report on four-year outcomes of the trial in coming months.
The Ontario government has committed to providing housing and supports to participants in the intervention arm on an ongoing basis following the conclusion of the trial. In addition, the At Home/Chez Soi helped to influence the province to set a goal to end chronic homelessness in Ontario within the next 10 years.
