The At Home/Chez Soi research demonstration project was implemented in response to three mutually compounding challenges: up to 200,000 people experience homelessness annually across Canada; 67 per cent of those reported experiencing challenges to their mental health in their lifetime; and issues associated with homelessness “costs seven billion dollars each year in healthcare, justice and social service use”.
These issues relate specifically to the requirement for people experiencing homelessness to prove that they are tackling personal issues such as addiction and mental health problems before they can become eligible for access to community services. Though these problems have worsened since deinstitutionalisation began in the 1970s, they received greater attention in the runup to Vancouver 2010. The UN received a human rights complaint from an Olympic watchdog group, and issued a set of recommendations relating to homelessness in Canada, and Vancouver in particular.
Studies had also demonstrated that First Peoples and other minority groups were less likely to access social services than their white counterparts. Therefore, one particular challenge lay in establishing a policy that might work swiftly to alleviate problems of homelessness, and thereby improve the lives of homeless populations and lead to future savings through reduced social service costs.
A related challenge of the At Home/Chez Soi project was to explore whether Housing First might usefully be applied in the Canadian context. Housing First was developed by Dr Sam Tsemberis in New York City in 1992, based on the belief that “housing is a human right”. The model provides immediate access to housing and support for individuals who are homeless and struggling with mental health and substance abuse issues, without the usual requirement to demonstrate sobriety before accessing housing services. A longitudinal study into the effectiveness of Housing First in New York City found that the programme “sustained an approximately 80 percent housing retention rate” for those with mental health issues.
At Home/Chez Soi was a four-year, multi-site research demonstration project initiated in October 2009. It was designed to introduce simultaneously a new policy for tackling homelessness, mental health issues and substance abuse, and to conduct a randomised controlled trial to prove the effectiveness of Housing First in the Canadian context. The federal government invested CAD110 million to examine the potential for this new approach to homelessness. The initiative was implemented in five sites – Vancouver, Winnipeg, Toronto, Montreal and Moncton – by the Mental Health Commission of Canada (MHCC).
Over 2,000 participants were grouped into those with high needs – who received Assertive Community Treatment (ACT) – or with moderate needs – who received Intensive Case Management (ICM). They were then randomly allocated to either the Housing First group or the Treatment As Usual (TAU) group. Participants in the Housing First group were able to choose the housing and supports they needed, the only requirements being that they meet with a member of the support team once a week and that they pay up to 30 percent of their rent-subsidised income towards housing. The TAU group received access to existing housing and support services in their areas.
While there were unique elements to each scheme in the five different sites, there was broad alignment of programme implementation for the intervention groups. ACT programmes consisted of multidisciplinary teams which included a psychiatrist, a nurse, and a peer specialist. These teams met daily, and staff were available seven days a week, with crisis management available at all times. For these groups, the staff to participant ratio was 1:10. ICM programmes were implemented by teams of case managers who managed services as required by the participants. These teams met at least monthly, and provided services twelve hours a day, seven days a week. As these groups’ needs were higher than expected, the staff to participant ratio rose from 1:20 to 1:16 as the project progressed.
The first objective was to consider whether Housing First could be introduced successfully in Canada, and whether it could respond to regional contexts and needs of minority groups. To this end, the initiative was tested across five sites: Vancouver, Winnipeg, Toronto, Montreal and Moncton. The project paid particular attention to ensuring that both the Housing First group and the TAU group were representative of the wider homeless communities. Moreover, the project employed a People With Lived Experience (PWLE) Caucus comprised of those who had experienced homelessness and used mental health services, in order to engage with stakeholders and analyse community integration.
The second objective was to analyse whether Housing First affected participants’ ability to remain stably housed and to explore in greater detail – through interviews – the ways in which stable housing improved their quality of life. To this end, quantitative and qualitative data were collected every three months over the course of two years.
Thirdly, the project looked at the impact of Housing First on the costs associated with homelessness and related mental health issues, and assessed the feasibility of a wider implementation of the policy. The project compared the costs of services incurred by the Housing First groups and the TAU groups in order to determine whether Housing First offered cost-savings and, if so, to what extent.
Finally, the project intended to assess how Housing First impacted on participants’ “quality of life, community functioning, and mental and physical health”. In order to explore this objective, the project examined the proportion of people who spent every night in stable housing during the final six months of the two-year project, and the average percentage of days spent in stable housing throughout the period. Researchers also conducted qualitative interviews with participants from all of the sites in order to provide a context for the numerical data.
The public impact
At Home/Chez Soi had a significant impact on the participants involved in the Housing First trial, and on future approaches to homelessness and mental health in Canada. The project was very successful in demonstrating the potential for Housing First to improve the lives of homeless populations significantly, and particularly those suffering from mental health and/or substance abuse issues. In all the five sites included in the project, Housing First dramatically improved rates of housing among participants. For example, the rate of full-time housing in the last 6 months of the study was 31 per cent for the TAU group compared to 62 percent for the Housing First group (both high needs and moderate needs). Similarly, while TAU participants spent 32 percent of their days in stable housing, Housing First participants spent 73 percent in stable housing. These differences are statistically significant and are very unlikely to be due to chance. Therefore, the research demonstration exercise was very successful in proving that Housing First, when adapted to local conditions, could swiftly improve opportunities to reduce homelessness and address related mental health and substance use issues.
Responses to the project were overwhelmingly positive. While participants’ past experiences continue to have an impact on their lives, “themes of self-determination, independence, empowerment, integration, and inclusion were themes that offered places of hope”. Those who have taken part in subsequent Housing First initiatives in Canada have demonstrated its impact on them personally. One participant who had managed to turn her life around through Housing First stated, “that’s what my goal was, to have a nice warm place to call my home”. Another article found that At Home/Chez Soi was “far more successful than previous programmes in providing stable housing to homeless people with mental health issues”, and gave the example of one participant who “said the programme allowed him to pay off debts, quit drinking and reconnect with his family after more than 30 years on the streets”. A further news item suggested that the project and its findings “raised hopes… that Canada may be on a path to reducing homelessness”.
However, there have also been some less positive outcomes to the project. For example, media reports around an incident involving an unsuccessful Housing First placement highlighted that “the system utterly failed…the former tenant”. Moreover, many authors note the difficulty of turning a research demonstration exercise into long-term policies. The 2014 Final Report suggests that the development of a full range of housing and support options that include rent supplements would allow people to find suitable housing. However, the general lack of access to good quality, affordable housing in Canada is another barrier for people experiencing mental illness and homelessness. The successful expansion of HF across Canada will depend on improved access to good quality, affordable housing.
Finally, the cost-savings aspect of the programme was the outcome that brought the greatest impact. At Home/Chez Soi demonstrated that “every CAD10 invested in Housing First services resulted in an average reduction in costs of other services of CAD9.60 for high needs participants and CAD3.42 for moderate needs participants”. This cost-effectiveness garnered significant media attention. Combining aspects of the public good concerning homelessness and substance abuse with demonstrated public service savings left a lasting impact on future policies and approaches.
Public Confidence Good
Popular perceptions about the project seem broadly related to its cost-effectiveness and its efficacy in tackling problems related to homelessness and mental health. One article, which echoed the findings of many, stated that “housing gives [homeless people with mental health issues] the security and stability to move ahead” and also highlights the fact that Housing First “is often cheaper than leaving people on the streets”.
Nevertheless, there remain cautionary notes in other sources. Some communities have voiced concern about Housing First being implemented in their area, citing such concerns as “a drop in housing prices, increased crime, a negative impact on tourism, safety issues for those living nearby and the idea that the facility could attract more homeless people”. There are other issues, such as the fear of apartments being abused and the worry that Housing First might be viewed as a one-size resolution for issues of homelessness and mental health.
Stakeholder Engagement Strong
Stakeholder engagement was placed at the core of At Home/Chez Soi and ensured that all stakeholders, including members of the homeless community, researchers, and policymakers, were able to input and guide the planning and implementation of the project. From the outset, At Home/Chez Soi promoted participants’ engagement with the project. In particular, the project employed PWLE to contribute qualitative data to the study and how it was conducted. The policy also engaged with minority groups, including First Peoples, in order to make sure that it did not replicate issues that had led to minorities’ reduced access to social services. The project also engaged with policymakers from the outset.
The project engaged with a wide range of stakeholders across the five different sites. In Moncton, stakeholders included the Department for Health and the Department for Social Development, although the report noted that both departments began to withdraw support towards the end of the project, due to budget restraints. In Montreal, stakeholders included the Agence de la Santé et des Services Sociaux de Montréal [the Agency for Health and Social Security of Montreal] and a new lobbying group, the Movement to End Homelessness in Montreal. However, both groups raised concerns over the project’s use of public funds to pay private landlords. Stakeholders in Toronto included the Streets to Homes programme, which is funded by the City of Toronto to help people transition from homelessness to stable housing.
The Site Final Report for Winnipeg provided a clear summary of the stakeholders and how they interrelated. Broadly speaking, stakeholders were split into:
- An advisory committee comprising the MHCC, the National Research Team, and working groups
- Lead research providers, including university teams, the Institute of Urban Studies, the Department of Psychiatry, and the Department of Community Health Services
- Support Services – the Mount Carmel Clinic, Housing Plus, the Aboriginal Health and Wellness Centre of Winnipeg, and Ma Mawi Wi Chi Itata Centre.
Such a clear demarcation of stakeholders and their roles reveals how research and policy teams coordinated their activities and were guided by national advisory committees.
Political Commitment Strong
Through a highly effective combination of rigorous research insights, easily translatable findings, and expedient timing, the At Home/Chez Soi project garnered significant political commitment. In order to complete such an extensive research demonstration project across five sites required a high degree of cooperation between government departments, policy organisations, and research teams. Moreover, the high cost of the project required coordinating a wide range of stakeholders and significant processes of accountability.
The research demonstration exercise emerged in response to a particular combination of immediate political concerns, including a human rights complaint about homelessness in the runup to Vancouver 2010. One aspect of stakeholder engagement was its use of “policy entrepreneurship, which entails taking advantage of windows of opportunity, and helping to bring together the ‘streams’ of problems, politics, and policy ideas” and promote and disseminate them effectively. Most significantly, being able to demonstrate the cost-effectiveness of the project dramatically enhanced its garnering of political commitment. Following on from the research demonstration exercise, the Canadian government announced that it would invest $600 million over five years (from 2014) in a Homelessness Partnering Strategy which employed the Housing First approach.
Clear Objectives Good
At Home/Chez Soi aimed to test the feasibility of implementing the Housing First approach in Canada and researching the effects of this different approach to homelessness when compared with the TAU model. As such, while the project objectives were clearly established, they were oriented more towards academic research than immediately towards policy outcomes.
While the objectives of the research demonstration exercise were to conduct a rigorous academic study, the extent to which it would lead directly to policy implementation was less obvious. As one article makes clear, there remained “concerns how the idea behind the At Home/Chez Soi was formulated more specifically in the policy arena to facilitate its adoption at the site level”. This suggests that there was a lack of attention to how the services implemented by the project would continue beyond its end and, relatedly, who would continue to fund the Housing First initiatives once the project had finished.
As At Home/Chez Soi constituted a research project from its inception, it is perhaps unsurprising that the evidence base and the evidence outputs were both very strong. Drawing on the successful implementation of Housing First in the US, the project began by assessing the potential for this new model when applied to the Canadian context. It aimed to demonstrate both its cost-effectiveness and its efficiency in transitioning homeless people suffering from mental health and/or substance use issues into stable housing.
The evidence of cost-effectiveness was widely shared and was backed up by robust data. Through engaging with participants over the course of five years, the study demonstrated a significant decrease in the numbers and rates of attendance at health care, justice, and social service institutions . In turn, this had a great effect on the public perceptions about how best to tackle homelessness and mental health issues, and the efficacy of implementing policies based on Housing First, in particular. As one participant in the study put it: “I am really proud of myself, with a lot of help I was… able to… not really get back to where I used to be, but in a better place”. As well as providing in-depth analysis of the economic and social effects of the project, it provided clear and simple findings that were easily disseminated and understood beyond academic and specialist audiences. Through monitoring the percentage of days spent in housing and the rate of full-time housing, the project demonstrated that Housing First was an effective means through which to enable those who are homeless to achieve stable housing. Participants in Housing First also demonstrated reduced overnight stays in hospitals, prisons, and addiction facilities. The project found that the greatest area of costs savings was in the prevention of psychiatric hospitalisation.
The At Home/Chez Soi project placed proving cost-effectiveness at the centre of its research and public pronouncements. While recognising that it is difficult to calculate the true costs of homelessness or of mental health and substance abuse issues, it clearly demonstrated the feasibility of the programme and the potential savings offered by this alternative approach.
One of At Home/Chez Soi’s undoubted successes was in demonstrating that implementing Housing First in the Canadian context could lead to significant cost-savings. As one of the project’s team wrote succinctly in CBC News: “the housing-first model saves money by curbing the over-consumption of services”. The project published figures that clearly indicated the potential for large savings in state services. For example, it cited figures such as “receipt of Housing First services for high needs participants resulted in average reductions of CAD21,375” and “for moderate needs participants receiving Housing First services, we found an average reduction of CAD4,849”. Such a simple demonstration of easy-to-grasp figures led to a significant shift in popular perceptions of Housing First policies in Canada.
In spite of the immense scale of the project – taking place across five different sites and working with a wide range of stakeholders – there were clear fidelity structures in place and a viable management structure to ensure that the project remained on track and that it followed the research model. There was a clear management structure from the national advisory groups down to the individual teams working with the project participants.
The original funding and management of At Home/Chez Soi was provided through the MHCC. During the period of the research demonstration exercise, the project was managed extremely well and yielded commensurately useful, policy-oriented results. A successful management and guidance structure was put in place at the beginning of the project, and stakeholder groups were employed to guide and contribute to its progress. While there were key differences across the five sites in line with each context’s unique requirements, there were clear stakeholder and participants structures demarcating expectations and responsibilities from the level of national policy to individual therapy groups.
However, at the end of the project, it was unclear who should take over the management of Housing First initiatives in Canada, and these unresolved long-term management plans have recently led to sustainability issues and point towards a need to build resiliency within programme implementation. Indeed, these issues relating to long-term resilience were noted by a number of researchers during the project. One report indicates that “while project leaders talked about prioritising sustainability… they acknowledged the difficulty of keeping the issue on the ‘front burner’, and defining clear expectations from the beginning, as well as underestimating the resources and time that the sustainability strategy would ultimately entail”. While this finding is perhaps unfair, given the project’s objective of only demonstrating future feasibility, it is nevertheless important to recognise these long-term limitations.
As the At Home/Chez Soi project was primarily one of measuring Housing First’s impact on participants, it had extremely strong measurement mechanisms. The MHCC’s rigorous, site-specific National Final Reports provide in-depth analysis of how the project was measured and the metrics adopted to explore and demonstrate impact.
Indeed, the management of the project was such that, according to one case study conducted in the area of Public Health, it became a prime example of how to create “rigorous and relevant evidence for implementing and evaluating complex population health interventions”. Across the five project sites, research groups collected both quantitative and qualitative data. Quantitative results included a comparison between the test and the control groups of the number of evenings spent in stable housing, and the rates of full-time housing for participants in the two groups in the final six months of the study. Qualitative data included the effects of immediate access to housing on perceived quality of life, and interviews about how these changes affected the way a person viewed their future and ability to integrate into the community.
The At Home/Chez Soi project was able to successfully and productively align the interests of policymakers, stakeholder groups, and research groups in order to provide an extensive research demonstration exercise. The political climate at the time ensured a focus on homelessness, partly because of the human rights complaint to the UN in the runup to Vancouver 2010. The project therefore was able to benefit from significant federal funding – administered by the MHCC – and from dedicated research teams. There was close alignment between stakeholders, and this remained the case until the end of the research project, with a minor exception of some policy and interest groups raising concerns over the project’s sustainability.
The project successfully drew upon and further cemented a strong alignment of interest between stakeholders, researchers and policymakers. At Home/Chez Soi capitalised on a strong political will, and by employing a key policy entrepreneur (then Senator and chair of the MHCC Michael Kirby), it was able to demonstrate the project’s impact on homelessness and mental health issues while also contributing public cost-savings. Through efforts to keep the project in the public imagination and by providing consistent and useful findings, it maintained an alignment of interest. Furthermore, the engagement of representative groups from PWLE and minorities such as First Peoples enabled the project to remain focused on issues that would be of real benefit to the affected communities, as well as to researchers and policymakers.