Supportive Housing Program for Homelessness

Recruiting at 1 trial location

Overseen By Andrew S Boozary, MD MPP CCFP

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University Health Network, Toronto

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 1 Jurisdiction This treatment is already approved in other countries

Compensation: Varies

Number of Visits: Unknown

100 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

The study design is a cohort study with a propensity score-matched control group and difference-in-difference analysis to evaluate intervention effectiveness. A hybrid type 1 effectiveness-implementation study framework is used that incorporates mixed methods to determine clinical effectiveness and explore implementation and participant well-being. Participants are selected based on their utilization of health services. Selection favoured those individuals with the most health service utilization. A control group will be created by selecting individuals from administrative hospital records that are propensity-score matched to the individuals in the treatment group (1:4 pair). The hybrid type 1 effectiveness-implementation study framework was used to guide the selection of study aims and outcomes to focus primarily on clinical effectiveness, while also exploring implementation-related factors. The primary objective of the study is to evaluate the impact of the Initiative on the number of emergency department visits and days spent in the hospital. The secondary objectives are to 2) evaluate the impact of the Initiative on program participants' health and well-being, 3) evaluate the implementation of the Initiative and assess program fidelity and barriers, and 4) to calculate the cost avoidance and cost-effectiveness of the Initiative.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It seems focused on housing and health service use, so it's likely you can continue your medications, but please confirm with the study team.

Is supportive housing safe for participants?

Supportive housing programs, which provide housing and support services, are generally considered safe for participants. However, there are challenges such as high-risk behaviors (like overdose and self-injury) that need to be managed to ensure safety and housing stability. ^{1 2 3 4 5}

How does the Social Medicine Housing Initiative treatment differ from other treatments for homelessness?

The Social Medicine Housing Initiative is unique because it combines subsidized housing with site-based social services, aiming to improve health and residential stability for homeless individuals. Unlike other treatments, it focuses on providing stable housing as a foundation for addressing health and social issues, which can lead to greater satisfaction with living situations and improved quality of life. ^{6 7 8 9 10}

What data supports the effectiveness of the treatment Social Medicine Housing Initiative for homelessness?

Research shows that supportive housing programs, like the Social Medicine Housing Initiative, can improve health and social outcomes for homeless individuals by providing stable housing and coordinated care, which includes access to physical health and social support services. ^{2 6 11 12 13}

Who Is on the Research Team?

Andrew Boozary, MD MPP CCFP

Principal Investigator

University Health Network, Toronto

Are You a Good Fit for This Trial?

This trial is for adults who are unhoused and have complex health needs, with frequent hospital visits—specifically, at least 2 inpatient admissions or 6 emergency department visits in the past 6 months. Priority is given to Indigenous people, those without housing recently, women, gender-diverse individuals, and people with disabilities.

Inclusion Criteria

The Housing Initiative is part of standard care and is not contingent on participating in any research activities. Patients that participate in the Housing Initiative will have the option to participate in the research study.

To qualify for housing through the initiative, patients must have had 2 or more inpatient admissions or 6 or more visits to the emergency department in the past 6 months. They must also either identify as Indigenous or be currently without housing, which is defined as having spent at least one night in a shelter or having received assistance from city-funded street outreach providers in the past 90 days. Historically marginalized groups, including people with disabilities, women, gender-diverse individuals, and Indigenous people, are given priority for housing. Eligible patients are prioritized for housing offers based on their use of the University Health Network emergency departments in the past year.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Intervention

Participants are provided with housing and support services as part of the Social Medicine Housing Initiative

30 months

Ongoing support and monitoring

Follow-up

Participants are monitored for health outcomes and healthcare utilization

30 months

Regular surveys and interviews

Data Analysis

Analysis of health data and cost-effectiveness of the program

Concurrent with intervention

What Are the Treatments Tested in This Trial?

Interventions

• Social Medicine Housing Initiative

Trial Overview The Social Medicine Housing Initiative is being evaluated through a cohort study comparing participants receiving the intervention to a matched control group from hospital records. The focus is on reducing emergency department visits and hospital stays while assessing participant well-being and cost-effectiveness of the program.

How Is the Trial Designed?

Group I: University Health Network Standard Care Experimental Treatment 1 Intervention

The Social Medicine Housing Initiative is part of standard care and is not contingent on participating in any research activities. Patients who participate in the Housing Initiative will have the option to participate in the research study. The Social Medicine Housing Initiative provides a housing-first approach which offers housing to individuals without prerequisites (e.g., requiring cessation of substance use, adherence to treatment). Through the Initiative, patients will receive access to permanent supportive housing and support services based on the Social Medicine model. Participants will not only have access to housing but will also be provided with customized social and medical support within and beyond the University Health Network, tailored to their specific needs and preferences.

Group II: Propensity score matched cohort Active Control 1 Intervention

The Institute of Clinical Evaluative Sciences of Canada database will provide health administrative data on the Housing Initiative individuals and similar individuals. Each individual in the treatment arm will be matched with four individuals (1:4 pair) in the control arm who are observationally similar. The propensity score-matched cohort method will control for demand-side characteristics that reflect the utilization of health care services, focusing on the use of emergency department visits and inpatient hospital days, nursing home use, and inpatient utilization for severe mental illness. To assess whether the propensity score model has adequately specified, the authors will examine whether the distribution of measured baseline covariates is similar between treated and untreated subjects with the same estimated propensity score.

Social Medicine Housing Initiative is already approved in United States for the following indications:

Approved in United States as Social Medicine Housing Initiative for:

• Complex health needs in unhoused adults

Who Is Running the Clinical Trial?

University Health Network, Toronto

Lead Sponsor

Trials

1,555

Recruited

526,000+

Published Research Related to This Trial

Patients in a permanent supportive housing (PSH) program reported positive experiences with care coordination for physical health and social support services, indicating that these programs can effectively address some healthcare needs for individuals experiencing homelessness.

However, gaps in mental health support and assistance with securing public benefits were identified, suggesting that while PSH programs are beneficial, there is still room for improvement in comprehensive care coordination.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Perceived care coordination among permanent supportive housing participants: Evidence from a managed care plan in the United States. Palimaru, AI., McBain, RK., McDonald, K., et al.[2022]

The Navigator Programme, a case management intervention for homeless patients, is being rigorously evaluated in a randomized controlled trial involving 640 adults to assess its effectiveness in improving posthospital outcomes, particularly follow-up care within 14 days of discharge.

The study aims to measure various outcomes, including postdischarge mortality, readmission rates, and quality of care transitions, over a 180-day period, highlighting the potential for structured support to enhance healthcare access for vulnerable populations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial. Liu, M., Pridham, KF., Jenkinson, J., et al.[2022]

Intensive case management significantly reduced the number of days individuals spent homeless and decreased substance and alcohol use, indicating its effectiveness in improving housing stability and health outcomes for homeless populations.

Assertive community treatment was found to be cost-effective compared to standard case management and showed protective effects against rehospitalizations, highlighting the importance of intervention intensity and tailored support in achieving better outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review. Ponka, D., Agbata, E., Kendall, C., et al.[2023]

Permanent supportive housing (PSH) significantly improves housing stability for individuals experiencing homelessness, particularly those with high needs related to mental illness and substance use, while also potentially reducing emergency department visits and hospitalizations.

While PSH shows clear benefits for housing stability, its impact on mental health, quality of life, and employment outcomes is inconsistent, indicating that additional support and interventions may be necessary to address these areas effectively.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. Moledina, A., Magwood, O., Agbata, E., et al.[2023]

Participants in a case management program for chronically ill, homeless individuals reported significant improvements in their health and well-being, largely due to the social support provided by case managers.

Key themes from interviews highlighted the importance of personal relationships with case managers, assistance in navigating healthcare systems, and the reduction of social isolation, suggesting that comprehensive social support is crucial for effective case management interventions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

"Because somebody cared about me. That's how it changed things": homeless, chronically ill patients' perspectives on case management. Davis, E., Tamayo, A., Fernandez, A.[2022]

This study outlines a protocol for a unique randomized controlled trial aimed at implementing overdose prevention practices in Permanent Supportive Housing (PSH) settings, involving 20 buildings across New York City and the Capital Region.

The trial will assess the effectiveness of tailored overdose prevention strategies, making it the first controlled study of its kind in PSH, which could significantly influence future approaches to reduce overdose risks in high-risk populations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The POP (Permanent Supportive Housing Overdose Prevention) Study: protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial. Doran, KM., Torsiglieri, A., Blaufarb, S., et al.[2023]

Supportive housing, particularly the 'housing first' model, is the leading approach in the U.S. for helping chronically homeless individuals achieve housing stability and improved health, but the implementation of this model varies significantly across programs.

Qualitative interviews in Chicago revealed six distinct types of supportive housing based on housing configuration and service models, highlighting the need for comparative effectiveness research to determine which combinations of components yield the best health outcomes for different homeless subpopulations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes. Dickson-Gomez, J., Quinn, K., Bendixen, A., et al.[2022]

Permanent supportive housing is effective for stabilizing individuals with homelessness and mental illness, but high-risk behaviors like overdose and violence pose significant challenges to housing stability.

The review identified various approaches to manage these high-risk behaviors, but highlighted a lack of rigorous evaluation of their effectiveness, indicating a need for further research to develop best practices in supportive housing settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review. Kerman, N., Kidd, SA., Mutschler, C., et al.[2023]

Only 4% of consumers in the Veterans Affairs Greater Los Angeles supported housing program exited before achieving housing placement, which is significantly lower than the national average of 18%.

Key factors leading to premature exits included residing in temporary housing, poor adherence to outpatient care, and substance use disorders, with over 50% of those who exited becoming street homeless or incarcerated afterward.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Factors Associated With Premature Exits From Supported Housing. Gabrielian, S., Burns, AV., Nanda, N., et al.[2022]

Veterans placed in a multidimensional, patient-individualized housing program based on ASAM criteria showed significantly better long-term outcomes, with none being readdicted after 12 months, compared to those in a protocol-driven 'wet' housing program who all relapsed.

The 'wet' housing program led to serious negative outcomes, including three imprisonments, one life-threatening medical issue, and one death, highlighting the importance of tailored treatment approaches and close monitoring in addiction recovery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Residential placement for veterans with addiction: American Society of Addiction Medicine criteria vs. a veterans homeless program. Westermeyer, J., Lee, K.[2022]

A study involving 855 residents of various permanent supportive housing (PSH) models found that individuals with serious mental illness (SMI), substance use disorders (SUD), or dual diagnoses were not more likely to be housed through the coordinated entry system (CES).

However, these individuals were more likely to be placed in PSH models that offered higher intensity services, suggesting that while CES did not prioritize them for housing, it did facilitate access to more supportive environments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Placement of chronically homeless into different types of permanent supportive housing before and after a coordinated entry system: The influence of severe mental illness, substance use disorder, and dual diagnosis on housing configuration and intensity of services. Dickson-Gomez, J., Quinn, K., McAuliffe, T., et al.[2022]

In a study of 112 homeless and vulnerably housed individuals in Toronto, those accepted into a supportive housing program reported significantly greater satisfaction with their living situation compared to those on the waitlist for usual care.

While the supportive housing program did not show significant differences in overall health status, health care utilization, or substance use, it demonstrated that disadvantaged individuals can achieve stable housing, highlighting the potential benefits of such programs.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program. Hwang, SW., Gogosis, E., Chambers, C., et al.[2022]

King County has created a coordinated system to prioritize access to supportive housing for individuals who are homeless and have serious mental illnesses or substance abuse issues, addressing the high demand for these resources.

The model focuses on individuals' usage of publicly financed services, such as emergency departments and hospitals, to ensure that the most vulnerable populations receive the necessary support.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Creating a Regional Model to Coordinate and Prioritize Access to Permanent Supportive Housing. Sylla, L., Franzen, R., Srebnik, D., et al.[2022]

Citations

1. England pubmed.ncbi.nlm.nih.gov

Perceived care coordination among permanent supportive housing participants: Evidence from a managed care plan in the United States. [2022]

2. England pubmed.ncbi.nlm.nih.gov

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial. [2022]

3. United States pubmed.ncbi.nlm.nih.gov

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review. [2023]

4. United States pubmed.ncbi.nlm.nih.gov

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. [2023]

5. United States pubmed.ncbi.nlm.nih.gov

"Because somebody cared about me. That's how it changed things": homeless, chronically ill patients' perspectives on case management. [2022]

6. England pubmed.ncbi.nlm.nih.gov

The POP (Permanent Supportive Housing Overdose Prevention) Study: protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial. [2023]

7. United States pubmed.ncbi.nlm.nih.gov

Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes. [2022]

8. England pubmed.ncbi.nlm.nih.gov

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review. [2023]

9. United States pubmed.ncbi.nlm.nih.gov

Factors Associated With Premature Exits From Supported Housing. [2022]

10. United States pubmed.ncbi.nlm.nih.gov

Residential placement for veterans with addiction: American Society of Addiction Medicine criteria vs. a veterans homeless program. [2022]

11. United States pubmed.ncbi.nlm.nih.gov

Placement of chronically homeless into different types of permanent supportive housing before and after a coordinated entry system: The influence of severe mental illness, substance use disorder, and dual diagnosis on housing configuration and intensity of services. [2022]

12. United States pubmed.ncbi.nlm.nih.gov

Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program. [2022]

13. United States pubmed.ncbi.nlm.nih.gov

Creating a Regional Model to Coordinate and Prioritize Access to Permanent Supportive Housing. [2022]