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?

This trial examines how providing supportive housing through the Social Medicine Housing Initiative affects the health and well-being of individuals who frequently use emergency health services. The researchers aim to determine if stable housing reduces emergency department visits and hospital stays. Participants will either receive housing and support services or be part of a matched comparison group using health records. This trial suits individuals who have recently had multiple hospital visits and either identify as Indigenous or are currently without housing. As an unphased trial, this study offers a unique opportunity to contribute to important research that could enhance housing and health outcomes for many.

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.

What prior data suggests that the Social Medicine Housing Initiative is safe for participants?

Research has shown that the Social Medicine Housing Initiative, which employs a "Housing First" approach, is generally well-received by participants. Studies have found that this method reduces homelessness by 88% and improves housing stability by 41%. The initiative quickly provides stable housing without requiring participants to stop using substances or follow specific treatments. No major reports of negative effects from the housing itself have emerged. This evidence suggests that the initiative is safe for participants, as it focuses on offering support services tailored to individual needs. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about the Social Medicine Housing Initiative because it uses a housing-first approach for addressing homelessness, which is different from many traditional programs that often require individuals to meet certain conditions, like sobriety, before receiving housing. This initiative provides immediate access to permanent supportive housing without prerequisites, ensuring that individuals get the stability they need right away. Additionally, it offers personalized social and medical support, tailored to each person's unique needs, which is a significant shift from the more generic support services typically available. This approach aims to improve health outcomes and reduce emergency room visits and hospital stays, offering a promising alternative to current options.

What evidence suggests that the Social Medicine Housing Initiative is effective for reducing emergency department visits and hospital days?

Research has shown that the Social Medicine Housing Initiative, part of the current trial, uses a "Housing First" approach that effectively reduces homelessness and increases housing stability. Studies indicate that participants in these programs spend more days in stable housing compared to traditional methods. This approach provides housing without requiring individuals to stop using substances first. Strong evidence suggests that Housing First leads to better long-term housing stability, proving it to be an effective solution for homelessness. Participants in this trial will also receive personalized social and medical support, enhancing their overall well-being. ^{1 2 3 6 7}

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

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC8513528/

Permanent Supportive Housing with Housing First to Reduce ... Evidence from this systematic review indicates that Housing First programs can more effectively reduce homelessness and improve housing stability for homeless ...

2. nlihc.org nlihc.org/sites/default/files/Housing-First-Evidence.pdf

THE EVIDENCE IS CLEAR: HOUSING FIRST WORKS – A systematic review found that, compared with usual care, permanent supportive housing programs result in a significant increase in the number of days spent ...

3. clinicaltrials.gov clinicaltrials.gov/study/NCT06723093

Evaluation of a Supportive Housing Program for Adults ... Through the Social Medicine Housing Initiative, patients will receive access to permanent supportive housing and support services based on a social medicine ...

4. endhomelessness.org endhomelessness.org/resources/toolkits-and-training-materials/housing-first/

Housing First Does Housing First work? ... There is a large and growing evidence base demonstrating that Housing First is an effective solution to homelessness.

5. archives.huduser.gov archives.huduser.gov/portal/periodicals/em/spring-summer-23/highlight2.html

Housing First: A Review of the Evidence | HUDU SER Several studies have found that, compared with the treatment first model, Housing First approaches offer greater long-term housing stability.

6. file.lacounty.gov file.lacounty.gov/SDSInter/dhs/1141587_AqualitativeevaluationofHousingforHealthinLosAngelesCounty.pdf

A qualitative evaluation of Housing for Health in Los ... PSH is an intervention model that provides housing and a range of supportive services to address co-occurring physical, mental, and social needs ...

7. homelessness.ucsf.edu homelessness.ucsf.edu/our-impact/studies/california-statewide-study-people-experiencing-homelessness

California Statewide Study of People Experiencing ... The UCSF Benioff Homelessness and Housing Initiative recently completed a new study to better understand homelessness across the state of California.