Research Demonstration Projects on Homelessness and Mental Health -Open Forum

Today’s Presentation

• Mental Health Commission of Canada

• Federal Agreement

• Research strategy

• Funding

• Structure

• Progress

Mental Health Commission of Canada

• Standing Senate Committee on Social Affairs,

Science and Technology in November 2005

• “Out of the Shadows at Last – Transforming

Mental Health, Mental Illness and Addiction

Services in Canada” May 2006

• Mental Health Commission of Canada established

fall 2007

• Board – 11 non-government members & 6

government members

Mental Health Commission of Canada

8 Advisory Committees to the Board

• Children and Youth

• First Nations, Inuit, and Metis

• Workforce

• Mental Health & the Law

• Service System

• Family Caregivers

• Seniors

• Science

Mental Health Commission of Canada

• Primary role as a catalyst

• Four major initiatives

• Development of a national strategy

• Anti-discrimination campaign

• Establish a knowledge exchange center

• Research demonstration project on mental

health and homelessness

Background – Homelessness Project

• Announced on February 26, 2008 as part of the Federal budget

• $110 m to MHCC to undertake five research demonstration projects in mental health and homelessness

• Project sites:

• Moncton

• Montreal

• Toronto

• Winnipeg

• Vancouver

• To occur over the next five fiscal years

• Funding Agreement signed March 30, 2008

Funding Agreement: Principles

• People with lived experience are central

• Development of a knowledge-base with respect to

the homeless mentally ill that will ultimately support

more effective interventions

• Build on related work to maximize scope of the

results and impact of the study

• Research ethically sound

• Support knowledge exchange

Funding Agreement: Principles cont.

• Work with communities to ensure lasting results and

buy-in

• Strive for long-term improvements in the quality of

life of participants

• Address fragmentation through improved system

integration.

• Plan for sustainability

• Foster collaborations and partnerships to avoid

duplication of efforts and to leverage funds

Project Definition

• Multi-site, four year, demonstration project aimed at providing policy relevant research evidence about what service and system interventions best achieve housing stability and improved health and well being for those who are homeless and mentally ill.

• Will include five cities, each with particular subgroups of interest.

• Will involve various stakeholders in a collaborative, integrated knowledge translation process.

• Funding to include research, rent subsidies, services and system integration components.

Core Research Design Requirements

• One common core research design for all sites

• Tailor site-specific demonstration projects

• Function and processes of intervention are standardized, whereas the form of the components may be tailored to local conditions

• Local studies may add sub-studies that are unique to their setting

Research design:

• Pragmatic, multi-site field trial of the effectiveness and costs of a complex community intervention using mixed methods

• Randomizing participants into experimental and control conditions

• Definition of the target group and the nature of the experimental condition must be common across the sites

• Comparisons to care as usual will be required in all cities

Research Strategy: Why multi-site?

• Opportunity to scale up quickly established best practice

approaches. i.e. “bring interventions that are proven and

effective to the public.”

• Pooling of data increases numbers and possibilities for

analysis

• Cross- site comparisons provide information about

implementation in different contexts and increases the

policy impact.

• Economy of scale for technical assistance, knowledge

exchange and network building

Research Strategy: Recommended Intervention

• Housing First-combines permanent housing in scattered site apartments with consumer choice and assertive community treatment. Very effective with difficult to serve, long term homeless with concurrent disorders.

• Considerable interest in current Canadian context- HRDC partnership initiatives, Streets to Home and LEAD in Toronto, Calgary Homeless Foundation

• Model could benefit from further enhancement (to include primary care and vocational outcomes) and replication/adaptation in Canadian context with broader population subgroups.

• Relative costs/benefits in comparison to alternative models will be of interest to field and to policy makers.

• Work on Canadian version of toolkit and fidelity scales underway in Calgary.

• Capacity for training and technical assistance available

Research DesignKey Elements of the Experimental Intervention:

Housing First Model

Recovery oriented culture

Based on consumer choice for all services

Only requirements: income paid directly as rent; visited at a minimum once a week for pre-determined periods of follow-up

supports

Rent supplements for clients in private market: participants pay 30% or less of their income or the shelter portion of welfare

Treatment and support services voluntary - clinicians/providers based off site

Legal rights to tenancy (no head leases)

No conditions on housing readiness

Program facilitates access to housing stock

Apartments are independent living settings primarily in scattered sites

Services individualized, including cultural adaptations

Reduce the negative consequences of substance use

Availability of furniture and possibly maintenance services

Tenancy not tied to engagement in treatment

(High Need)

Recovery-oriented ACT team

Client/staff ratio of 10:1 or less and includes a psychiatrist and

nurse

Program staff are closely involved in hospital admissions and

discharges

Teams meet daily and include at least one peer specialist as

staff

Seven day a week, 24 hr crisis coverage

(Moderate Need)

Intensive case management for a minimum of one year once

housed

Client/staff ratio of 20:1 or less

Integrated efforts across multiple workers and agencies

Workers accompany clients to appointments

Centralized assignment and monthly case conferences

Seven day a week, 12 hours per day coverage

Research DesignPartnerships – Building Capacity and Sustainability

• Encourage and support collaboration and partnerships with

federal, provincial, municipal, not-for-profit and private

sectors in order to leverage funds, avoid duplication of

efforts, and build a foundation for sustainability

• Proponents should describe the in kind and direct

contributions of partner organizations and jurisdictions in

relation to both the research and service aspects of the

proposed Research Demonstration projects

• Sites are expected to aim for a minimum of 20% leveraging

of funds over the duration of the project

Research DesignFunds Available and Allowable Costs:

• Site coordinators can assist local teams

• Allowable costs include evaluation, rent subsidies, support services, furniture and property management costs

• Capital expenditures above $10,000 are not allowable costs

• The services will be a minimum of 85% of the budget and will include rent subsidies as well as a range of support services

• In Vancouver, Toronto and Montreal the maximum allowable rent subsidy is $600 per person; in Winnipeg and Moncton, the maximum allowable rent subsidy is $400 per person

• The maximum allowable cost for an ACT team serving 100 people is $1.1M.

• The maximum allowable cost for ICM support system for 100 people is $0.5M.

Research DesignSupplemental Funding

• A complementary funding pool has been established with

CIHR’s Partners for Health Systems Improvement program

to support applied research studies that fall outside of the

research demonstration projects but with the scope of the

federal funding agreement.

• Funding for local system integration will be made available

through a supplementary process during the second year of

the project

Project Structure

• MHCC Project Lead – Jayne Barker

• National Research Team led by Paula Goering

• National Working Group

• Consumer advisory committee

• National training and data capacity

• 5 local research/provider teams funded through RFA process

• 5 site advisory committees

• 5 site coordinators

National Research Team

• Carol Adair, University of Calgary

• Tim Aubry, University of Ottawa

• Paula Goering, CAMH, University of Toronto

• Jeffrey Hoch, St. Michael’s Hospital, University of Toronto,

University of Western Ontario

• Geoff Nelson, Wilfrid Laurier University

• Myra Piat, Douglas Mental Health University Institute;

McGill University

• David Streiner, Baycrest Hospital; University of Toronto

• Sam Tsemberis, Pathways to Housing, Inc

Progress to Date

• Agreement with Health Canada completed

• Initial engagement at each site

• Lit scan and key informant interviews with multi-site

investigators

• Consultation re project design with Science AC

• Selection of members of the national research team

• Planning workshop-July 30, 31st

• Draft RFA-Aug 2008

• Site Coordinators hired – Aug. 2008

Progress to Date

• Consultation Forums in each city- Sept/Oct

2008

• Post RFA – Nov 7, 2008

• Applications due Jan 23rd, 2009

• Select site research teams from RFA –

Jan./Feb 2008