Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto

Abstract

Background: The At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.

Methods: Homeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.

Results: The effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.

Conclusions: Recruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.

Figure 1

Participant flow through study. *Operational definitions for High Needs vs. Moderate Needs. High Needs participants must have: 1) A score <62 on the Multnomah Community Ability Scale (MCAS); AND 2) A Mini International Neuropsychiatric Interview (MINI) diagnosis of current psychotic or bipolar disorder OR observations of psychotic disorder by referral source; AND 3) One of: a) Two or more hospitalizations for mental illness in any one year in last five years OR b) Co-morbid substance use OR c) Recent arrest or incarceration (or don't know or declined to answer). All other eligible participants were considered Moderate Needs. ^#Participants with Moderate Needs who self-identified membership in an Ethno-Racial group were given a choice to participate in a regular ICM program or an Ethno-racial focused ICM program, as long as space was available in both groups.