Supportive Housing Settings Research Articles

What are important ingredients for Intensive Home Support for people with severe mental illness according to experts? A concept mapping approach

BackgroundDeinstitutionalization in mental health care has been an ongoing process for decades. More and more people with severe mental illness (SMI), who previously lived in residential supported housing settings and were formerly homeless, are now living independently in the community but need intensive support to enable independent living. The support provided by regular outpatient teams is inadequate for this target group. This study explored the ingredients for an alternative form of outpatient support: intensive home support (IHS).MethodsConcept mapping was used, following five steps: (1) brainstorming, (2) sorting, (3) rating, (4) statistical analysis & visual representation, and (5) interpretation. Purposive sampling was used to represent several perspectives, including researchers, professionals, peer workers, and policy makers.ResultsExperts (n = 17) participated in the brainstorming step and the sorting and rating steps (n = 14). The 84 generated statements were grouped into 10 clusters:. (1) housing rights; (2) informal collaboration; (3) reciprocity in the community; (4) normalization and citizenship; (5) recovery; (6) sustainable funding; (7) equivalence; (8) flexible, proactive 24/7 support; (9) public health and positive health; and (10) integrated cooperation in support at home.ConclusionsGiven the diversity of the ingredients contained in the clusters, it seems that IHS should be designed according to a holistic approach in collaboration with several sectors. Additionally, IHS is not only the responsibility of care organizations but also the responsibility of national and local governments. Further research about collaboration and integrated care is needed to determine how to implement all of the ingredients in practice.

Delivering collaborative mental health care within supportive housing: implementation evaluation of a community-hospital partnership

BackgroundApproaches to address unmet mental health care needs in supportive housing settings are needed. Collaborative approaches to delivering psychiatric care have robust evidence in multiple settings, however such approaches have not been adequately studied in housing settings. This study evaluates the implementation of a shifted outpatient collaborative care initiative in which a psychiatrist was added to existing housing, community mental health, and primary care supports in a women-centered supportive housing complex in Toronto, Canada.MethodsThe initiative was designed and implemented by stakeholders from an academic hospital and from community housing and mental health agencies. Program activities comprised multidisciplinary support for tenants (e.g. multidisciplinary care teams, case conferences), tenant engagement (psychoeducation sessions), and staff capacity-building (e.g. formal trainings, informal ad hoc questions). This mixed methods implementation evaluation sought to understand (1) program activity delivery including satisfaction with these activities, (2) consistency with team-based tenant-centered care and with pre-specified shared lenses (trauma-informed, culturally safe, harm reduction), and (3) facilitators and barriers to implementation over a one-year period. Quantitative data included reporting of program activity delivery (weekly and monthly), staff surveys, and tenant surveys (post-group surveys following tenant psychoeducation groups and an all-tenant survey). Qualitative data included focus groups with staff and stakeholders, program documents, and free-text survey responses.ResultsAll three program activity domains (multidisciplinary supports, tenant engagement, staff capacity-building) were successfully implemented. Main program activities were multidisciplinary case conferences, direct psychiatric consultation, tenant psychoeducation sessions, formal staff training, and informal staff support. Psychoeducation for tenants and informal/formal staff support were particularly valued. Most activities were team-based. Of the shared lenses, trauma-informed care was the most consistently implemented. Facilitators to implementation were shared lenses, psychiatrist characteristics, shared time/space, balance between structure and flexibility, building trust, logistical support, and the embedded evaluation. Barriers were that the initial model was driven by leadership, confusion in initial processes, different workflows across organizations, and staff turnover; where possible, iterative changes were implemented to address barriers.ConclusionsThis evaluation highlights the process of successfully implementing a shifted outpatient collaborative mental health care initiative in supportive housing. Further work is warranted to evaluate whether collaborative care adaptations in supportive housing settings lead to improvements in tenant- and program-level outcomes.

Living with dementia in supported housing: A systematic review and thematic synthesis of qualitative research.

Supported housing has been highlighted as a potential way to facilitate independent living for people with dementia by integrating housing with support or care services. However, the benefits and challenges of living with dementia in supported housing are not fully understood. This systematic review and thematic synthesis sought to understand how living in supported housing influences the lives of people with dementia, from the perspectives of people with dementia, their supporters, health and social care professionals. Seven databases were searched for qualitative research, date range: 1 January 2000-31 July 2021. Eleven published articles were included in the thematic synthesis. One core theme was generated, Maintaining Independence and Autonomy, divided into three subthemes - Support and Care, Social Relationships and the Physical Environment. Factors like person-centred care, social interaction and good environmental design contributed to the maintenance of independence and autonomy. Barriers like low staff ratios, stigma and limited access to the community led to a loss of independence and autonomy - often leading to people with dementia being referred or managed out of the settings. Although the articles acknowledged the importance of maintaining independence and autonomy for people with dementia, it appeared that supported housing settings often lacked the resources and facilities to make this a reality. More high-quality research is needed, particularly from the perspectives of people with dementia and their supporters, to understand if supported housing can delay care home admission, promote independence and autonomy and facilitate social networks and community connections for this population.

Exploring factors related to supportive housing tenure and stability for people with serious mental illness.

Overall, the retention of people with serious mental illness (SMI) in supportive housing is high. However, some supportive housing settings report average stays of only 15 months, and others report declines in housing retention over time. Many studies report variables associated with supportive housing stability and tenure, but there are few extensive, focused investigations on the subject.Hence, a literature review was conducted to investigate factors associated with supportive housing stability and tenure among people with SMI. The review of the included 28papers revealsthatthe factors associated with supportive housing stability and tenure fell into two general categories of individual factors (including psychiatric factors and prior homelessness), and contextual factors (including program characteristics and sense of community and social support). In conclusion, further focus on contextual factors, as well as a potential reframing of individual factors as contextual, may be helpful in addressing issues related to supportive housing stability and tenure for people with SMI.

IPS in Supported Housing: Fidelity and Employment Outcomes Over a 4 Year Period

Background: People with severe mental illness have difficulties finding and maintaining competitive employment. This is particularly so for those living in supported housing who, by definition, have significant day-to-day support needs: in the Netherlands only 3 to 5% of people with serious mental health problems who live in supported housing are competitively employed. To support these people in finding and maintaining competitive employment, Individual Placement, and Support (IPS) was introduced within supported housing services in the Netherlands in 2015. As this is the first country that broadly implemented IPS in supported housing settings, this paper will focus on the first results regarding feasibility and effects on employment in clients of IPS in this sector.Methods: We investigated the feasibility and employment outcomes of delivering IPS in supported housing services using fidelity assessments and quarterly employment outcomes on IPS program level within eight supported housing organizations, and compared these with 21 mental health treatment organizations in the Netherlands over a 4 year period. We investigated possible reasons for our findings and their implications through qualitative evaluations of the IPS fidelity assessors' notes and additional focus groups with IPS specialists and coordinators from supported housing services and fidelity assessors.Results: The overall fidelity scores indicated reasonable implementation of the IPS model within both supported housing services and mental health services. However, there were differences between services with regard to specific fidelity items; mental health treatment organizations scored higher for team integration, whereas supported housing services scored higher for rapid job search and caseload size, diversity of jobs, and employers. Our qualitative data suggested that the difference in team integration between the two sectors was due to differences in their organizational and financial structures, as well as in the specific needs of their clients. Conversely, supported housing services had better connections with employers which facilitated more rapid job searching and greater diversity in employment opportunities. The average total client employment rate did not significantly differ; and was 25.8% per quarter in supported housing services and 29.6% in mental health treatment services.Conclusion: Implementing IPS in supported housing settings is both feasible and effective.

Association between primary heath care and dental service use among supportive housing tenants with behavioral health conditions.

Homeless persons are at high risk for poor oral health. Supportive housing can improve housing stability for persons with behavioural health conditions, but its impact on dental service use has been little studied. Data for this evaluation come from matched public service records for eligible applicants to a New York City supportive housing program (NY III) targeting chronic homelessness. NY III tenants (N=5678) were compared with applicants not placed in housing (N=6536) and applicants placed in other supportive housing programmes (N=4823). Regression analysis was used to assess the association between supportive housing, primary care use, clinical severity and the likelihood of dental visits. Over four observation years, 71% of applicants had at least one dental visit for any cause and 57% for preventive dental care. Incidence of dental visits was lower for persons with physical disability (IRR=0.91; 95% CI=0.85, 0.97, P=.003), psychiatric hospital stays (IRR=0.78; 95% CI=0.68, 0.88, P<.001) and age over 54. Persons engaged in primary care (IRR=1.26; 95% CI=1.21, 1.31, P<.001) and outpatient mental health care (IRR=1.16; 95% CI=1.12, 1.21, P<.001) had greater incidence of dental visits. Supportive housing was associated with greater dental service use. The positive association between primary care, mental health care and dental care suggests important points of entry for dental care. Oral health education and service referrals in supportive housing and primary care settings may improve oral health service delivery to persons experiencing social exclusion due to homelessness, mental illness and poor oral health.

Independent Housing and Support for non-homeless individuals with severe mental illness: randomised controlled trial vs. observational study \u2013 study protocol

BackgroundSocial inclusion is essential for an adequate rehabilitation process for people with serious mental illness (SMI). Various supported housing settings aim to promote housing competencies and social inclusion in service users. Nevertheless, there is a strong preference in service users for independent living. We aim to evaluate the effectiveness and efficiency of Independent Housing and Support (IHS) compared to institutionalised residential care settings and other treatment as usual conditions (RCS/TAU) in two cities in Switzerland.MethodsThis is a prospective multi-centre, four-arm, non-inferiority cohort study investigating the effectiveness and efficiency of IHS and RCS/TAU for people with SMI. Effectiveness will be measured by a standardised measure of social inclusion as primary outcome as well as by measures of functioning and well-being. Efficiency will be analysed on the basis of service usage and costs associated with the different housing settings. Participants will be consecutively recruited and subsequently enrolled between April 2019 and December 2020 and assessed at baseline and after six, twelve and after 24 months. At one study site, 56 participants will be randomly assigned to one of the conditions; the other study site will be conducted as an observational study investigating 112 admitted participants.DiscussionWhile the UN Convention of the Rights of People with Disabilities aims to promote the opportunity to choose one’s place of residence, the limited supply of alternative forms of housing does not guarantee genuine freedom of choice. Increased diversification and flexibility of housing support is essential. If IHS shows non-inferiority in terms of their effectiveness and efficiency, users should be allowed to choose their kind of housing support.Trial registrationClinicalTrials.gov: NCT03815604, December 04, 2019.

The ambiguous influences of fire safety on people with mental health problems in supported housing

Over the last few decades, various housing types for people with mental health problems have been developed for use in the community. These housing types differ in their objectives, staff support and design. In this study, we focus on how fire safety influences the lives of tenants in supported housing. The qualitative study was designed with a multi-sited ethnography approach. Fieldwork was conducted in seven different Norwegian supported housing settings in 2017 with 105 participants (29 tenants, 70 staff, five managers, and one planner). The empirical data consist of field notes, recorded interviews and pictures, which were analyzed with grounded theory and situational analysis. The analysis reconstructed how fire safety was organized and tenants’ experiences of it. These experiences could be positive (such as feeling protected) or negative (such as feeling annoyed or under surveillance). The tenants coped differently with these situations, and fire safety sets boundaries for tenants. Overall, fire safety was organized differently in the supported housing settings we looked at comparison to in most of the common housing units in Norway. The influences of fire safety on daily life can be understood as ambiguous and can be interpreted as a normalizing factor in a risk society. Thus, we emphasize the need for appropriate and well-considered fire safety as a public health intervention in supported housing.

Increasing Psychiatric Rehabilitation Knowledge in a Supported Housing Setting: Pre- and Posttest Analysis.

The current study investigated the effectiveness of a state-wide Community Support Services training grounded in work-based learning to improve knowledge about psychiatric rehabilitation principles and skills. Supervisory staff and direct care staff in supported housing settings completed a 17-item, multiple choice, preand posttest after attending a 48-hour training series. Results indicated that participants gained psychiatric rehabilitation knowledge. These findings support the effectiveness of the training series grounded in work-based learning. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 39-44.].

Feasibility Pilot Outcomes of a Mammography Decision Support and Navigation Intervention for Women With Serious Mental Illness Living in Supportive Housing Settings.

Objective: People with serious mental illness (SMI) experience significant disparities in morbidity and mortality from preventable and treatable medical conditions. Women with SMI have low mammography screening rates. SMI, poverty, and poor access to care can have a significant effect on a woman’s opportunity to learn about and discuss breast cancer screening with health care providers. This study examines the feasibility pilot outcomes of mammography decision support and patient navigation intervention (DSNI) for women with SMI living in supportive housing settings. The primary research question was: Does the DSNI increase knowledge, promote favorable attitudes, and decrease decisional conflict relating to screening mammography? Methods: We developed the intervention with the community using participatory methods. Women (n = 21) with SMI who had not undergone screening mammography in the past year participated in an educational module and decision counseling session and received patient navigation over a 6-month period. We conducted surveys and interviews at baseline and follow-ups to assess mammography decisional conflict. Results: Among study participants, 67% received a mammogram. The mammogram DSNI was feasible and acceptable to women with SMI living in supportive housing settings. From baseline to 1-month follow-up, decisional conflict decreased significantly (P = .01). The patient navigation process resulted in 270 attempted contacts (M = 12.86, SD = 10.61) by study staff (phone calls and emails with patient and/or case manager) and 165 navigation conversations (M = 7.86, SD = 4.84). A barrier to navigation was phone communication, with in-person navigation being more successful. Participants reported they found the intervention helpful and made suggestions for further improvement. Conclusions: The process and outcomes evaluation support the feasibility and acceptability of the mammography DSNI. This project provides initial evidence that an intervention developed with participatory methods can improve cancer screening outcomes in supportive housing programs for people with SMI.

Realizing the Truth to Help Others: A Photovoice Investigation of Barriers to Healthy Living in People with Serious Mental Illness

Reaching for a Healthier Lifestyle:A Photovoice Investigation of Barriers to Healthy Living in People with Serious Mental Illness Lara Carson Weinstein, MD, MPH, DrPH, Mariana Chilton, PhD, MPH, Renee Turchi, MD, MPH, Ann Klassen, PhD, Marianna LaNoue, PhD, Stephan Lamar, Sandra Yorgey, Lois Kramer, Irwin Smith, and Leopoldo Cabassa, MSW, PhD What Is the Purpose of this Study? • To investigate social and structural factors that affect weight loss in partnership with community co-researchers enrolled in a group lifestyle program for overweight/obese people with serious mental illness (SMI) living in supportive housing settings. What is the Problem? • People with mental illness in the United States are almost twice as likely to be obese compared with those without a mental illness. • Lifestyle factors, such as poor dietary choices and physical inactivity, are often cited as causes of obesity in this population, which limits the response to the obesity epidemic primarily to behavioral change interventions. • In response, this project is grounded in a human rights framework to ensure that the people most affected by the problem are included in understanding and addressing the problem. What Are the Findings? • Co-researchers selected 33 photos reflecting two overarching themes: 1) structural barriers, such as poor quality food, transportation costs, limited Supplemental Nutrition Access Program (SNAP) benefits, limits of food pantries, easy availability of tobacco and alcohol products, and limited places for exercise, and 2) strategies for overcoming structural barriers, such as healthy eating on a budget. • Co-researchers highlighted structural barriers that were a cause or consequence of food insecurity and situations that threaten the right to healthy food and opportunities for a healthy life. • Co-researchers reported examples of knowledge and skills they learned through participation in the project that were used to overcome structural barriers to healthy eating and physical activity, and likely contributed to weight loss. Who Should Care Most? • Health practitioners who care for people with SMI who are obese, to better understand the multilevel challenges to healthy eating and physical activity. • Researchers developing interventions to support health in people with SMI, to recognize the importance of addressing the social determinants of health in new interventions. • Policymakers, to understand the impact of cuts to programs such as the SNAP and Social Security, and how these cuts disproportionally affect the health of people with disabilities. [End Page 335] Recommendations for Action • Provide opportunities for populations affected by complex health problems to offer real-life insights to inform intervention development and help to address hidden and important barriers to achieving a healthy life in the community. • Continue to support creative community-based participatory research approaches, such as Photovoice, to provide opportunity for deeper dialogue and engagement with marginalized populations. • Advocate for structural and policy level changes to increase the availability of healthy food options in low-income neighborhoods, improve income supports, maintain and increase food subsidies, and incorporate changes to the built environment to support physical activity, to ensure the right to food and the right to health for people with psychiatric disabilities. [End Page 336] Lara Carson Weinstein Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Mariana Chilton Health Management and Policy, Dornsife School of Public Health, Drexel University Renee Turchi Community Health and Prevention, Dornsife School of Public Health, Drexel University Ann Klassen Community Health and Prevention, Dornsife School of Public Health, Drexel University Marianna LaNoue School of Population Health, Thomas Jefferson University Stephan Lamar Pathways to Housing PA Sandra Yorgey Pathways to Housing PA Lois Kramer Pathways to Housing PA Irwin Smith Pathways to Housing PA Leopoldo Cabassa Brown School of Social Work, Washington University in St. Louis Copyright © 2019 Johns Hopkins University Press

Functional Limitations Experienced by Older Adults with Complex Care Needs and Its Impact on Access to Community Based Health and Social Care

Introduction: Multimorbidity is often combined with functional limitations among older adults. It is therefore important to ensure the built and social environment encourages older adults to safely age while maintaining independence. Previous findings have focused on the impact of the built environment as a barrier to an active lifestyle, but not specific to accessing community-based health and social care (CHSC). We propose to investigate the impact of patient and caregiver limitations on accessing care, including the impact of the built environment. Methods: Secondary thematic coding analysis was undertaken with 53 patient and 38 informal caregiver interviews from communities in Canada and New Zealand. Reported findings are from a broader research program titled, Implementing integrated Care for Older Adults with Complex Health needs (iCOACH). Older complex seniors were recruited for participation from a community primary healthcare team if they were greater than 50 years of age, and managing ongoing chronic conditions. Caregivers were unpaid informal carers of older adults. A specific thematic code about unmet need was extensively reviewed for examples related to the built environment and access to care. Results: Functional limitations hindered self-management at home as well as accessing CHSC. Attributes of the physical environment at home impacted the use of assistive devices, and impaired the ability to leave the home. Physical barriers within the social environment included the inability to use public transportation, access community programs, and conduct daily living tasks. Consequences from not being able to access supports included greater financial strain, social isolation, poor safety at home, lack of independence, and greater caregiver strain. Older adults appeared to be less impacted by access barriers when living in supportive housing settings, where on-site staff were available to provide direct support, or initiate referrals for additional services. Discussions: Experiences of older adults and informal caregivers highlighted access to care issues specific to the immediate and external physical environment, and examples of when support was efficiently provided. When considering how to best deliver services to people with complex care needs and their caregivers, it is important to consider how those services can be accessed. Conclusions: When services cannot be easily accessed, patients and caregivers may make critical trade-offs. To maintain independence and safety, it is important to design services which consider the adaptations and supports that are required to support older adults both at home, as well as the environment they have to navigate to access care. Lessons learned: CHSC should be delivered to ensure increased accessibility. Providing health services which are close in proximity to primary care providers, or co-locating may be more efficient and accessible. Community programs should consider the broad range of limitations in designing holistic services for older adults and their caregivers. Limitations: Transferability of findings may be limited, as rural community-dwelling seniors and participants with cognitive decline were not included in the study. Suggestions for future research: Further explore the barriers to improving access to medical and social care from policy and provider perspectives, and create solutions that can be explored and implemented.

Two-year outcomes of the Early Risers prevention trial with formerly homeless families residing in supportive housing.

This article reports 2-year outcomes from a cluster randomized, controlled trial of the Early Risers (ER) program implemented as a selective preventive intervention in supportive housing settings for homeless families. Based on the goals of this comprehensive prevention program, we predicted that intervention participants receiving ER services would show improvement in parenting and child outcomes relative to families in treatment-as-usual sites. The sample included 270 children in 161 families, residing in 15 supportive housing sites; multimethod, multi-informant assessments conducted at baseline and yearly thereafter included parent and teacher report of child adjustment, parent report of parenting self-efficacy, and parent-child observations that yielded scores of effective parenting practices. Data were modeled in HLM7 (4-level model accounting for nesting of children within families and families within housing sites). Two years' postbaseline, intent-to-treat (ITT) analyses indicated that parents in the ER group showed significantly improved parenting self-efficacy, and parent report indicated significant reductions in ER group children's depression. No main effects of ITT were shown for observed parenting effectiveness. However, over time, average levels of parenting self-efficacy predicted observed effective parenting practices, and observed effective parenting practices predicted improvements in both teacher- and parent-report of child adjustment. This is the first study to our knowledge to demonstrate prevention effects of a program for homeless families residing in family supportive housing.

Commentary on “Communication is the key: improving outcomes for people with learning disabilities”

PurposeThe purpose of this article is to provide a commentary on Lewer and Harding's article about the use of “the open communication tool”(OCT).Design/methodology/approachThis article reviews the OCT as a method of both developing shared goals and understandings and identifying implementation issues.FindingsThe OCT can provide a useful model when working in services. It might be enhanced by also including ways of systematically addressing the views of the person with a learning disability and their family members.Originality/valueIndirect interventions delivered in the way described may be problematic in that some research suggests that staff teams place greater value on knowledge that is directly gained by experience of working with the person. This raises questions relating to the model within which clinical services are often delivered to supported housing settings and whether this needs to change.

Assisted Living and Special Populations: What Do We Know About Differences in Use and Potential Access Barriers?

The purpose of this article was to review existing knowledge about assisted living (AL) use by traditionally underserved populations, including people of color, low-income people, and those living in rural communities. We reviewed methodologies and findings of research on AL and residential care up to June 2004. Some studies suggested that low-income people and people of color either are less likely to utilize AL or receive AL in settings with less space and amenities and/or lower scores in selected quality measures. Generalizations from national or multistate studies to the population have methodological limitations. Numerous topics remain unstudied, including the pricing of AL, the experience of choosing an AL facility, the presence of discriminatory admission and retention practices, and the role of resident preferences. Data on access to AL in rural areas are inconclusive. We offer recommendations for national surveys to better classify supportive housing settings. Furthermore, we suggest quantitative and qualitative studies to illuminate the experience of low-income, racial/ethnic minority, and rural populations in AL settings.