Program Fidelity and Adaptation: Challenges in Implementing Housing First in Ireland

1
EUROPEAN RESEARCH CONFERENCE
Housing First. What’s Next?
Berlin, 20th September 2013
Program fidelity, adaptation, & outcomes:
Challenges in implementing Housing First
in Ireland
Dr Ronni Michelle Greenwood
Sean Bromfield
Dublin Model of Homeless Services Delivery

2
Housing First. What’s Second?
Gap in the Plan
 No direct access to
housing
 No supported
housing for people
to high support
needs/”entrenched
rough sleepers”
Dublin Housing First Demonstration
Project
 No additional resources
 Voluntary part-time team
 No direct HF experience
 Sent a small group to New York
 Team leader/CEO of Stepping Stone
 HSE – not on board -- no psychiatry –
 Steering Committee
 Programme Evaluation

3
Dublin HF Demonstration:
Phase 1Challenges
 Housing
 Support Services
 Overlap between landlord & service
provider
 Intake & Eligibility criteria
 Legal Entity
Dublin Housing First
Phase 1 Challenges: Housing
 Housing sources
 Four housing units
 Social housing
 Voluntary agencies
 Peter McVerry Trust
 Cluid
 Private rental
 Housing locations
 Homeless in
‘wrong’local authorities
 Housing types
 Bedsits
 One bedroom
 Two bedroom

4
Dublin Housing First
Phase 1 Challenges: Team
Team leader:
 Landlord and service provider
 Management style; leadership
Team members: Voluntary, part-time
Training in housing first approach
Compilation
 SA specialist/psychiatric nurse
 Key workers – part time
 Business in the community
Turnover
Team meetings
Year 1 Challenges
 Intake
 ‘The list of 23’
 The list of about 100
 Eligibility Criteria
 Rough sleeping: How much
 Motivation/’Buy in’

5
End of the Beginning:
Year 1 Review to March 2013
 Decline in tenancies
 Evictions
 Staff turnover and staff non-replacement
 Questions raised about management and
accountability
Phase 2: A new beginning
 Events
 Team leader resigned
 Full replacement of team members
 Legal entity
 Accountability to Dublin Regional Homeless
Executive
 Outcomes improving
 Intake, tenancies, retention
 Housing
 Staffing
 Case notes – transparency and accountability

6
Summary of Process Evaluation
Findings
 Lack of housing
 Leadership
 Overlap of landlord and service provider
 Intake and Eligibility
 Accountability
OUTCOME FINDINGS

7
Outcome Evaluation
 Design
 Housing First
 Non-equivalent Comparison Group
 Data
 Collected every three months
 Moving baseline
 Face-to-face data collection
 NY Housing Study tracking procedures
 Measures from NY Housing Study & Canadian Study will
allow cross-site comparisons
Participant Numbers
T1 T2 T3 T4 T5 T6 T7
HF 23 14 11 9 6 6 5
Comparison 14 11 11 9 9 7 6
* 3 Clients Deceased- HF

8
Participant Characteristics
 Age:
 Housing First = 42.09
 Comparison = 37.12
 Sex:
 Housing First: 15 Men, 5 Women
 Comparison: 10 Men, 6 Women
 Relationship – Single
 Housing First: 13
 Comparison: 10
ETHOS - Stably Housed
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
T1 T2 T3 T4
Housing First
Comparison

9
ETHOS - Emergency Housing
ETHOS - Short Term Housing
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
T1 T2 T3 T4
Housing First
Comparison

10
ETHOS - Institutions
ETHOS - Long Term
Residential
0
0,05
0,1
0,15
0,2
0,25
0,3
T1 T2 T3 T4
Housing First
Comparison

11
ETHOS - Rough Sleeping
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
T1 T2 T3 T4
Housing First
Comparison
Medical Services
 Past 3 Months
 6 Items Yes/No
 Medical / dental
 Overnight hospital
 Emergency room
 Clinic visit
 Care for teeth
 Other
0
0,5
1
1,5
2
2,5
T1 T2 T3 T4
Housing First
Comparison

12
SA/ETOH Services
 Past 3 Months
 8 items; Yes/No
 Any treatment
 Detox
 Talk about with
someone
 Meet doctor/nurse
 AA meeting
 Groups
 Other
0
0,5
1
1,5
2
2,5
3
3,5
T1 T2 T3 T4
Housing First
Comparison
Legal Issues
 Past 3 Months
 4 items; Yes/No
 Arrested
 Detained overnight
 Court
 Summons
0
0,5
1
1,5
2
2,5
T1 T2 T3 T4
Housing First
Comparison

13
Psychiatric Symptoms
 Colorado Symptom
Index
 13 items
 0=not at all; 4 = at
least every day
 Anxiety, depression,
psychosis
0
0,5
1
1,5
2
2,5
T1 T2 T3 T4
Housing First
Comparison
General Well-being
 14 Items
 0 = Never; 5 =
Everyday
 Happy, interested in life,
satisfied
 Something important to
contribute to society
 People are basically good
 Life has a sense of
direction or meaning0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
T1 T2 T3 T4
Housing First
Comparison

14
SA-related problems
 7 items
 1 = past month, 5 =
Never/Not applicable
 Used weekly or more
often
 Caused social
problems
 Spent a lot of time
getting, using, feeling
effects
 Withdrawal problems
0
0,5
1
1,5
2
2,5
3
T1 T2 T3 T4
Housing First
Comparison
Coercion (Choice)
 6 items
 0=Never; 4=Always
 Required to engage in
SA or take medicine
 Housing svc where
not allowed SA/ETOH
 Required to stay in
treatment
 SA/ETOH rules too
restrictive
0
0,5
1
1,5
2
2,5
T1 T2 T3 T4
Housing First
Comparison

15
Consumer Choice
 16 Items
 1 = no choice at all; 5
= completely my
choice
 Place you stay
overnight
 People who stay
 Who can come over
 Food you buy1
1,5
2
2,5
3
3,5
4
4,5
T1 T2 T3 T4
Housing First
Comparison
Reflections on Adaptation and Fidelity
 Varied adaptations in early phases limited
the demonstration’s reach
 Key challenges
 Housing availability
 Team processes
 Adaptations to intake, eligibility
 Adaptations to team meetings
 Participant outcomes are cause for
optimism for the future

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Future: What’s Second?
 Dissemination across Ireland
 Major housing services providers are publicly aligning
themselves with a ‘Housing Led’ approach;
 What, exactly, is ‘Housing Led’? – a necessary but
not sufficient component of HF
 Program Adaptation & Dilution are key
concerns
 Adopting the name but not the key ingredients
 Absorption into continuum of care providers
 Working within a system that has a ‘housing shortage’
 ‘Housing led’ is not necessarily ‘consumer-led’
 Leaving out those who have the most needs
THANK YOU FOR LISTENING.
Any questions?

Program Fidelity and Adaptation: Challenges in Implementing Housing First in Ireland

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Program Fidelity and Adaptation: Challenges in Implementing Housing First in Ireland