1

Critical Characteristics of Critical Characteristics of Supported HousingSupported Housing

Bonnie Kirsh, PhD.University of Toronto

Rebecca Gewurtz, MSc(OT), PhD CandidateUniversity of Toronto

Ruth A Bakewell, MSc(OT)University of Toronto

2

BackgroundBackground

High proportion of persons with SMI who High proportion of persons with SMI who are homeless.are homeless.Pressing need for effective SH that Pressing need for effective SH that improves outcomesimproves outcomesCharacteristics of SH that are valued and Characteristics of SH that are valued and effective are unknown, EG:effective are unknown, EG: Nature and intensity of supportsNature and intensity of supports Organizational structure to deliver supportsOrganizational structure to deliver supports Qualities of physical and social envir of SHQualities of physical and social envir of SH

3

PurposePurpose

To develop an understanding of importantTo develop an understanding of importantcomponents of supported housing (SH) forcomponents of supported housing (SH) forpersons with severe mental illness (SMI).persons with severe mental illness (SMI).

4

ObjectivesObjectives

Identify critical characteristics of SH as Identify critical characteristics of SH as perceived by residents and service providersperceived by residents and service providersIdentify best practice SH characteristics Identify best practice SH characteristics documented in literaturedocumented in literatureUnderstand influence of characteristics on Understand influence of characteristics on outcomesoutcomes

These characteristics can be used for quality These characteristics can be used for quality improvement and to set standards for SHimprovement and to set standards for SH

5

MethodsMethods

Comprehensive literature review, Comprehensive literature review, extraction of characteristics that affect extraction of characteristics that affect outcomesoutcomesQualitative methods Qualitative methods –– to understand lived to understand lived experience of SHexperience of SH Semistructured interviews with residents, SPsSemistructured interviews with residents, SPs Analysis: Constant comparative method to Analysis: Constant comparative method to

generate set of characteristicsgenerate set of characteristics

6

ParticipantsParticipantsConsumers/Residents, n=25Consumers/Residents, n=25

Type of ParticipantType of Participant Agency 1Agency 1 Agency 2Agency 2

Rent Geared to Income Rent Geared to Income <1 yr<1 yr>1 yr>1 yr

2266

1133

HomelessHomeless<1 yr<1 yr>1 yr>1 yr

1155

1133

MH & JusticeMH & Justice<1 yr<1 yr>1 yr>1 yr

N/AN/AN/AN/A

33

TotalTotal 1414 1111

7

Participants (cont’d)Participants (cont’d)

Service Providers, n=10Service Providers, n=10Housing support workerHousing support worker 55Case manager/Rehab workerCase manager/Rehab worker 55

8

Results: Themes GeneratedResults: Themes GeneratedConsumersConsumers Service ProvidersService Providers

Guiding principlesGuiding principles Guiding principlesGuiding principlesSupports offered in supportive Supports offered in supportive housinghousing

Supports offered in supportive Supports offered in supportive housinghousing

Housing featuresHousing features

Neighbourhood and community Neighbourhood and community Neighbourhood and community Neighbourhood and community

Moving forward: impacts of SHMoving forward: impacts of SH Moving forward: impacts of SHMoving forward: impacts of SH

Pathways into SHPathways into SH Pathways into SHPathways into SH

Program and system issuesProgram and system issues

9

Consumers: Guiding PrinciplesConsumers: Guiding Principles

Being Treated with DignityBeing Treated with Dignity a person with genuine value and wortha person with genuine value and worth confident that SPs were working hard on their confident that SPs were working hard on their

behalfbehalfFlexibility and Choice Flexibility and Choice Flexibility and choice in nature and frequency Flexibility and choice in nature and frequency

of supportof support Choice in housing unitChoice in housing unit

10

“The good thing about that was the housing “The good thing about that was the housing worker I had, I was given choices…she worker I had, I was given choices…she

would come with a list and said okay, this would come with a list and said okay, this is where we have housing, it’s up to you...” is where we have housing, it’s up to you...”

[resident]. [resident].

11

Service Providers: Guiding Service Providers: Guiding PrinciplesPrinciples

Flexibility and Choice Flexibility and Choice individualized supportindividualized support choice (in neighbourhoods, housing type)choice (in neighbourhoods, housing type) range within the systemrange within the system

ClientClient--CentrednessCentredness clientclient--chosen goals, indep decisionchosen goals, indep decision--makingmaking information necessaryinformation necessary collaborationcollaboration

Managing StigmaManaging Stigma Segregated vs Integrated HousingSegregated vs Integrated Housing Support and education for LandlordsSupport and education for Landlords

12

Consumers: Supports offered in SHConsumers: Supports offered in SH

Access to SupportsAccess to SupportsSome felt they needed more support/ greater accessSome felt they needed more support/ greater accessGreater need for developing skills for independent livingGreater need for developing skills for independent living

Nature of SupportsNature of Supports Instrumental Support Instrumental Support

Taking care of house & home, managing financesTaking care of house & home, managing finances Support During a CrisisSupport During a Crisis Support with Work and SchoolSupport with Work and School

This extended support is key to moving forwardThis extended support is key to moving forward Informal Supports Informal Supports

Importance of friendships, family, petsImportance of friendships, family, petsConnections with other consumersConnections with other consumers

13

“…Well most of the people that I have “…Well most of the people that I have become really good friends with are the become really good friends with are the people in the program…you meet these people in the program…you meet these incredible people who have thriving incredible people who have thriving lives…who were exactly where I was…I lives…who were exactly where I was…I mean it’s just why it’s so powerful…these mean it’s just why it’s so powerful…these are my friends…which is incredible.”are my friends…which is incredible.”

14

SPs: Supports offered in SHSPs: Supports offered in SHBuilding a RelationshipBuilding a Relationship

Fostering trust key to relationshipFostering trust key to relationship--buildingbuildingPatience & persistence, not ‘giving up’ Patience & persistence, not ‘giving up’ High SP turnover a challenge to relationshipHigh SP turnover a challenge to relationship--buildingbuilding

AccessAccessImportance of longImportance of long--term support, often the only term support, often the only supportsupportCommunity supports/resources beyond housing Community supports/resources beyond housing Advocacy Advocacy -- Some resources difficult to access Some resources difficult to access

Supporting Independent LivingSupporting Independent LivingTransition to indep living is like “cultureTransition to indep living is like “culture--shock”shock”Importance of routineImportance of routineSupport in making apartment into a homeSupport in making apartment into a homeImportance of paying attention to needs beyond Importance of paying attention to needs beyond housinghousing

15

Service Provider: Service Provider:

“Having the supports I think is important … like “Having the supports I think is important … like in our case our caseloads are kept low. So that in our case our caseloads are kept low. So that we can have the time to spend with clients.. So we can have the time to spend with clients.. So we can go in and see them twice a week. You we can go in and see them twice a week. You know three times if we absolutely have to.. And know three times if we absolutely have to.. And we can spend an hour or more with them if we we can spend an hour or more with them if we need to.. you know if it’s needed, not to make a need to.. you know if it’s needed, not to make a habit of it, but if it’s needed we can.. so it’s not a habit of it, but if it’s needed we can.. so it’s not a 15, 20 minute visit …And I just, I think that 15, 20 minute visit …And I just, I think that makes a big difference.”makes a big difference.”

16

SPs: Supporting Independent SPs: Supporting Independent LivingLiving

Instrumental SupportsInstrumental SupportsFinances, paying rent, learning budgeting skills Finances, paying rent, learning budgeting skills Education about financial options (eg. trustee, Education about financial options (eg. trustee, income support programs) income support programs) Support when dealing with unpaid rentSupport when dealing with unpaid rent

Social SupportsSocial SupportsCombating isolation, establishing a social network Combating isolation, establishing a social network

Support with Work and EducationSupport with Work and Education Support During a CrisisSupport During a Crisis

Creating ‘crisis plans’, being attuned to client’s lifeCreating ‘crisis plans’, being attuned to client’s lifeWorking closely with landlords/ superintendents Working closely with landlords/ superintendents important in crisis prevention and managementimportant in crisis prevention and management

Support Managing Health Support Managing Health Medications, improving physical health, ageing Medications, improving physical health, ageing clientsclients

17

“Ultimately trying to get the individual to do “Ultimately trying to get the individual to do most of the stuff their own. To encourage most of the stuff their own. To encourage that independence… this is their home, that independence… this is their home, this is their place… it’s not my home. To this is their place… it’s not my home. To help them set up, to make it their help them set up, to make it their sanctuary… it’s such an important thing in sanctuary… it’s such an important thing in people’s life, not just to have a roof over people’s life, not just to have a roof over their head, but a place that they can have their head, but a place that they can have that pride in and that happiness with. And that pride in and that happiness with. And the more control they have over it, the the more control they have over it, the more sense of ownership.”more sense of ownership.”

18

Consumers: Housing FeaturesConsumers: Housing FeaturesIndependent LivingIndependent Living Living alone fundamental to privacy & dignityLiving alone fundamental to privacy & dignity Important for recovery and goal attainmentImportant for recovery and goal attainment Sense of safety & control Sense of safety & control Pride in making house into a homePride in making house into a home Able to organize routine around personal prioritiesAble to organize routine around personal priorities Reduces stress, provides flexibility, stability, motivationReduces stress, provides flexibility, stability, motivation Drawback Drawback -- lonelinessloneliness

Important Structural FeaturesImportant Structural Features Rent subsidyRent subsidy Physical space (separate bedroom, appliances, fresh Physical space (separate bedroom, appliances, fresh

paint, good building maintenance & services)paint, good building maintenance & services) Opportunities to socialize locallyOpportunities to socialize locally Stability of arrangement Stability of arrangement –– no maximum length of no maximum length of

stay/tenurestay/tenure Increased comfort, security, stability, reduced stressIncreased comfort, security, stability, reduced stress

19

“when I go back now to my own unit, I’m “when I go back now to my own unit, I’m able to assess and process what took able to assess and process what took place that day, and what should be place that day, and what should be happening next. So that gives me my own happening next. So that gives me my own space to do that.”space to do that.”

20

When you boil it right down, because I’m When you boil it right down, because I’m now living in a clean secure [place],...I’m now living in a clean secure [place],...I’m just in… an overall better frame of mind… just in… an overall better frame of mind… and therefore more likely to do the proper and therefore more likely to do the proper things to take care of myself.... I have my things to take care of myself.... I have my own kitchen, my own bathroom, so I don’t own kitchen, my own bathroom, so I don’t have to wait for other people to get out of have to wait for other people to get out of the shower. I can lay food somewhere the shower. I can lay food somewhere without people stealing it…You know, it’s without people stealing it…You know, it’s just yeah… the overall ease of living.. just yeah… the overall ease of living.. psychologically it’s picked me up a fair bit.. psychologically it’s picked me up a fair bit..

21

Consumers: Neighbourhood & Consumers: Neighbourhood & CommunityCommunity

DisclosureDisclosure Scattered apartments vs clustered housingScattered apartments vs clustered housing Dealing with stigmaDealing with stigma Shared understanding and a community of supportShared understanding and a community of support

Community AccessCommunity Access Public transit & amenities (banks, stores, relig cong)Public transit & amenities (banks, stores, relig cong) Proximity to supports (family, friends, drs, MH progs)Proximity to supports (family, friends, drs, MH progs)

Interactions with NeighboursInteractions with Neighbours Various levels of interaction and supportVarious levels of interaction and support Increased sense of security and reduced stressIncreased sense of security and reduced stress

Safety: Impact of Drugs and CrimeSafety: Impact of Drugs and Crime Communities with high rates of drugs and crimeCommunities with high rates of drugs and crime Social housing vs subsidized units buildingsSocial housing vs subsidized units buildings Participants with histories of addiction require ‘clean’ Participants with histories of addiction require ‘clean’

buildings and communitiesbuildings and communities

22

“When you live in that building and you “When you live in that building and you come out, nobody, there’s not.. there’s come out, nobody, there’s not.. there’s nothing on your hat saying, he has a nothing on your hat saying, he has a mental illness or he lives in social housing, mental illness or he lives in social housing, or anything… you are one of the tenants, or anything… you are one of the tenants, nobody know who you are, or whatever nobody know who you are, or whatever illness you have.. and that type of illness you have.. and that type of integration, it is very good.. it, it gives you integration, it is very good.. it, it gives you hope...” (M13)hope...” (M13)

23

“You know when they say, when you’re in Rome “You know when they say, when you’re in Rome do as the Romans do. Well, when you’re in those do as the Romans do. Well, when you’re in those places and you’re living there, eventually...you places and you’re living there, eventually...you can’t fight them forever and then you give in… can’t fight them forever and then you give in… and you get high, and you drink with them, and and you get high, and you drink with them, and before you know it, you’re brought right down to before you know it, you’re brought right down to the level that they’re at… I didn’t want to be the level that they’re at… I didn’t want to be around that so, they got me a spot in a around that so, they got me a spot in a condominium building and, they got me a condominium building and, they got me a beautiful condo, and that got me away from the beautiful condo, and that got me away from the drugs, and that crowd, you know what I mean.”drugs, and that crowd, you know what I mean.”

24

SPs: Neighbourhood & CommunitySPs: Neighbourhood & CommunityCommunity Response to SHCommunity Response to SH Generally positive, some neighbourhoods more Generally positive, some neighbourhoods more

accepting of SH than othersaccepting of SH than others Difficulties arise when clients become unwell and are Difficulties arise when clients become unwell and are

unable to access medical services unable to access medical services Fit Fit –– Person to NeighbourhoodPerson to Neighbourhood Finding a good fit is key part of intake assessmentFinding a good fit is key part of intake assessment Importance of safe and healthy neighbourhoodsImportance of safe and healthy neighbourhoods Services and accessibility in neighbourhoods Services and accessibility in neighbourhoods Neighborhood critical for clients with substance use Neighborhood critical for clients with substance use

issuesissuesSafe, Comfortable, Clean Housing Safe, Comfortable, Clean Housing Critical to selfCritical to self--esteem and a sense of selfesteem and a sense of self--worth worth ––

SPs help maintainSPs help maintain Importance of building maintenanceImportance of building maintenance Good housing is about more than having shelter; it is Good housing is about more than having shelter; it is

about creating a homeabout creating a home

25

“When we do the assessment, we’re looking for “When we do the assessment, we’re looking for fit. Cause we already know the landlords in the fit. Cause we already know the landlords in the buildings that we have out there. So we want buildings that we have out there. So we want people to feel like they’re being integrated into a people to feel like they’re being integrated into a community, that they’re fitting in, that they don’t community, that they’re fitting in, that they don’t stand out. So someone that might want to live stand out. So someone that might want to live downtown and that would fit into the downtown downtown and that would fit into the downtown community, you know we’re not going to stick community, you know we’re not going to stick them out at say Don Mills and Sheppard where them out at say Don Mills and Sheppard where they might stand out. And vice versa. So we they might stand out. And vice versa. So we really look at the building, the makereally look at the building, the make--up of the up of the community, where people request that they want community, where people request that they want to live, and we try to match it that way. Cause at to live, and we try to match it that way. Cause at the end of the day we want people to be the end of the day we want people to be successful in housing. We want it to work.”successful in housing. We want it to work.”

26

Consumers: Moving Forward : Consumers: Moving Forward : Impacts of Supported HousingImpacts of Supported Housing

Impact of good housing Impact of good housing Increased selfIncreased self--esteemesteem Increased motivation: to improve selfIncreased motivation: to improve self--care, to care, to

participate in community lifeparticipate in community lifeBeing productiveBeing productive Valued being productive, involved in communities, Valued being productive, involved in communities,

having a schedule, connecting with othershaving a schedule, connecting with others Being able to pursue their goals improved recovery, Being able to pursue their goals improved recovery,

overall health and QoLoverall health and QoL Taking care of the home as productive workTaking care of the home as productive work SH provided opportunity and flexibility to pursue goalsSH provided opportunity and flexibility to pursue goals

Hopes for the futureHopes for the future Safe and secure housing allowed participants to Safe and secure housing allowed participants to

process past experiences and begin to think about process past experiences and begin to think about the futurethe future

27

“It’s allowed me to stop worrying about those “It’s allowed me to stop worrying about those things that were holding me back. When I was in things that were holding me back. When I was in the rooming houses, I wasn’t able to even think the rooming houses, I wasn’t able to even think about the things that I’m doing now…because I about the things that I’m doing now…because I was so suppressed with all this negative energy was so suppressed with all this negative energy and these negative things going on around me. I and these negative things going on around me. I just felt hopeless and trapped. But due to my just felt hopeless and trapped. But due to my housing situation being changed, and I have a housing situation being changed, and I have a beautiful home and I’m happy there, now I’m beautiful home and I’m happy there, now I’m learning to be happy with me... I’m a good learning to be happy with me... I’m a good person and I have a good life, things are going person and I have a good life, things are going good, I’m going to go out today and I’m going to good, I’m going to go out today and I’m going to be a nice person, and I’m going to have a good be a nice person, and I’m going to have a good day. And I’m going to do, I’m going to help day. And I’m going to do, I’m going to help somebody if I can, and I’m going to make somebody if I can, and I’m going to make somebody smile, stuff like that…I can focus on somebody smile, stuff like that…I can focus on more positive things, now.”more positive things, now.”

28

SPs: Moving Forward: Impacts of SHSPs: Moving Forward: Impacts of SHHousing as a foundationHousing as a foundation Foundation for recovery and community integrationFoundation for recovery and community integration A “first step” towards stability and independenceA “first step” towards stability and independence Consistency in housing is necessary for ‘moving on’ Consistency in housing is necessary for ‘moving on’

to occurto occurGoals of SHGoals of SH Maintain housing; a “healthy, happy, safe” home Maintain housing; a “healthy, happy, safe” home

environmentenvironment Move on to more independent living situationsMove on to more independent living situations Participate in social rec and productive roles; work Participate in social rec and productive roles; work

and school and school Integrate into broader communityIntegrate into broader community Risk: isolationRisk: isolation

Increased confidence and stabilityIncreased confidence and stability demonstrated in ability to access and use resourcesdemonstrated in ability to access and use resources

29

“It [supported housing] allows people to feel that “It [supported housing] allows people to feel that they’re part of the community and move forward they’re part of the community and move forward with their life. Whatever that might look like. with their life. Whatever that might look like. Move their life with their journey. Be part of the Move their life with their journey. Be part of the community ... A mental illness is just one piece community ... A mental illness is just one piece of the puzzle of a person, who the person is, it’s of the puzzle of a person, who the person is, it’s not they’re whole existence it’s just a little piece, not they’re whole existence it’s just a little piece, and often people don’t feel that way. Often and often people don’t feel that way. Often they’re not led to feel that way… You’re a person they’re not led to feel that way… You’re a person first that has all sorts of goals and aspirations first that has all sorts of goals and aspirations and your identity is not the fact that you have a and your identity is not the fact that you have a mental illness.”mental illness.”

30

Literature: CharacteristicsLiterature: CharacteristicsSafetySafetyStigmaStigmaIndependenceIndependenceCoordination of servicesCoordination of servicesChoiceChoicePrivacyPrivacyFinancial AssistanceFinancial AssistanceBalanceBalanceNeighbourhoodNeighbourhoodSkillsSkillsSubstance/drug abuse Substance/drug abuse

treatmenttreatmentSocial SupportSocial SupportStaffStaffPermanencyPermanencyControlControl

RulesRulesIntegrationIntegrationIsolationIsolationCommunityCommunityMedicationMedicationSpaceSpacePreferencePreferenceSubsidySubsidyCase managementCase managementOptionsOptionsFlexibilityFlexibilityAffordabilityAffordabilityAccessAccessSharingSharingResourcesResources

31

ConclusionConclusion

Housing is a determinant of mental health Housing is a determinant of mental health Foundation for productive, meaningful Foundation for productive, meaningful engagement in life engagement in life Choice, individualized approach criticalChoice, individualized approach criticalNeighbourhood fit, no time limitsNeighbourhood fit, no time limitsAwareness and attention to stigmaAwareness and attention to stigmaRelationship key, long term supportRelationship key, long term supportSupports needed: independent living, crisis, Supports needed: independent living, crisis, work/school, social life, healthwork/school, social life, health