This study is a follow-up to the national At Home/Chez Soi randomized controlled trial (2009-2013). The At Home/Chez Soi study provided ‘Housing First’ (i.e. rent supplements and case management support as a first step to recovery) to people across the country who were experiencing homelessness and severe mental illness. After the study concluded, we continued to follow-up with participants and analyze the Toronto data. These follow-up results explore how Housing First can affect participants over the long term.

When the first follow-up stage of the Toronto arm of the At Home study concluded in 2015, the results demonstrated that the At Home version of Housing First leads to housing stability for most people experiencing both homelessness and mental health problems.

However results also showed that the At Home version of Housing First did not have a significant effect on other aspects of participants’ wellbeing (measured with quantitative instruments), such as quality of life, community functioning, substance use, and mental health problems.

This lack of improvement was unexpected; Housing First programs are situated within a theoretical framework that assume that long-term housing stability and supports will lead to improvements in a range of non-housing outcomes including health status and community integration — once the individual experiencing homelessness achieves housing stability. Yet, the results did not support these assertions.

About This Study

To investigate and better understand the At Home/Chez Soi results, we launched a qualitative, follow-up study in a sample of Toronto participants in the study who received Housing First services and rent supplement over the period 2009-2017. Our follow-up study aims to answer the following questions:

1. What circumstances, challenges, experiences, and unmet needs may have prevented participants from achieving better social, health and recovery outcomes while receiving long-term Housing First services? We are examining individual factors (e.g. poor health status, lack of social networks, risky behaviors); potential gaps within the Housing First program (e.g. mismatch between the services provided and client needs), as well as structural barriers (e.g. discrimination, lack of facilitated access to social/health services, lack of economic support).
2. What social, community, and health services or activities were (from the participants’ perspectives) crucial to recovery? We will identify elements that have helped clients to meet their individual needs and to feel part of their communities and society in general.
3. What additional services, activities and resources could be integrated into existing social programs to achieve better health and social outcomes for people experiencing homelessness and severe mental illness? We are exploring this question based on the findings from objectives 1 and 2 above, and accounting for gender- and age-specific needs.
4. What challenges are Housing First frontline service providers experiencing, and what solutions and strategies could be adopted to overcome them?

We plan to recruit and interview 28 participants who received At Home Housing First support from 2009 to 2017, as well as nine front-line team staff from the agencies that provided Housing First services to At Home participants (Across Boundaries, COTA, and Toronto North Support Services).

COVID-19: Understanding the Effects

The COVID-19 pandemic has transformed the service landscape for people experiencing homelessness and mental illness, and has intensely magnified many of the health and social challenges facing people experiencing homelessness and mental illness.

We are also exploring the following questions related to COVID-19:

1. What specific challenges and/or changes are affecting At Home participants’ abilities to remain stably housed, safe and healthy during the COVID-19 pandemic? How have participants needed to adjust and adapt?
2. How have COVID-19-related public health and social distancing measures impacted participants’ access to housing, social and health supports?
3. What additional social, health, and economic supports (in addition to Housing First) are participants receiving during the COVID-19 pandemic?

The Outcome

Our study goal is to inform Housing First programs, health and social service provision, as well as policy and future research to improve the delivery of Housing First programs. Because these programs and activities will — for the forseeable future — be delivered in the context of COVID-19, our study reflects this new reality.