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

Abstract

Background: Approaches 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.

Methods: The 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.

Results: All 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.

Conclusions: This 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.

Keywords: Collaborative; Community-hospital partnership; Psychiatry; Supportive housing.

Fig. 1

Initiative design. ¹Rostered tenants were tenants in supportive housing/Indigenous-specific units who had complex mental health needs, required additional support, and who consented to information sharing between WCH, the YWCA, and the Jean Tweed Centre. ²Case conferences involved the psychiatrist, YWCA staff, Jean Tweed Centre staff, and, when available, primary care (WCH family physician/Jean Tweed nurse practitioners). ³Psychoeducation sessions served to introduce the psychiatrist, improve mental health knowledge, and destigmatize mental health. They were facilitated by YWCA staff, with the psychiatrist (and the family physician, when available) providing expertise on the chosen topic. ⁴Direct consultation was either 1:1 with the tenant and psychiatrist, or when requested by the patient and team, was joint with the tenant, psychiatrist, and staff from YWCA and/or Jean Tweed