Research Matters Blog
Calgary has a 10 Year Plan to End Homelessness. And the Calgary Homeless Foundation has set very aggressive targets and benchmarks to reframe how our city thinks about and responds to homelessness. As a community, we have decided that it is completely inappropriate for a city of opportunity, like Calgary, to ignore the fact that we have 3,500 homeless men, women and children on our streets and in emergency shelters.
We have created 40 new programs in the last five years to move people from homelessness into housing with supports. Finding housing in our city is a key challenge – but just as critical is ensuring people have supports around them whenever they need them to keep that housing. The support piece is called case management. When working with homeless people, case management has to meet the needs of people with very complex lives and difficult histories. Case management should be person-centred, and delivered by a team of people from varying backgrounds. Open, honest communication and a non-judgemental approach are the keys to success as is ensuring people have an equal role in making decisions.
When case management is done well and people are engaged in the process, it changes lives. So far we have housed and supported 4,500 people in our housing and case management programs. Eighty to ninety percent remain in housing. These individuals are using jails and emergency rooms 54-85% less than when they were homeless and most importantly they are safe, secure and supported. We see dramatic results that cost taxpayers significantly less than ignoring the issue. We know that it can cost upwards of $100,000 per person per year to use emergency shelters, and public systems when they are homeless. Our most expensive case management program is $36,000 per person, per year. Most are around $20,000. Each person in a case management program plays an active part in paying rent and accessing supports and many move into volunteer roles, education or employment.
Case management along with safe, affordable housing is a critical part of the success of our 10 Year Plan. We are well on our way to creating a diverse and adaptable system of care that can meet and respond to this complex issue. Our ending homelessness work in Calgary is helping to build a strong community where all Calgarians can take advantage of the great things our city of opportunity has to offer.
Katrina Milaney is the Acting Vice President of Strategy for the Calgary Homeless Foundation. Katrina has been a researcher for several years engaged in numerous collaborative projects that uncover the root causes of social issues including poverty and homelessness. She has a Master’s degree in Community Health Sciences and is currently pursuing a PhD in Interdisciplinary Studies.
A friend of mine, who teaches at York University, recently lamented the fact that “The students in my class, they don’t read newspapers any more”. Well, I still like to read newspapers myself, but that's not the only way I like to get information. I follow twitter, I’m on Facebook, I use Youtube for everything from watching music videos, to seeing web-based comedy, to figuring out how to do a home repair. People consume information and, perhaps more importantly, learn new things in all kinds of ways, many of them mediated through technology.
You see, the world has changed, and as a researcher and an educator focused on the issue of homelessness, I am very interested in figuring out how to help the public – as well as decision-makers in government and the community – understand that in responding to homelessness, we can do things differently, and that we must. Through our work at the Homeless Hub, we recognize that it just isn’t enough to just push out academic papers that nobody wants to read; that if we really want people to engage research, we need to think differently about how people might want to consume information, and do things differently.
This is why I was blown away when I saw the NFB’s Here At Home interactive website and video series. This site, and the many videos contained within it, is perhaps one of the richest sources of information on homelessness – and how to address it – that I have seen. Right from the opening sequence, which draws you in to the site, to the important facts and figures relating to the five research sites, to the huge number of short video subjects, this is a site that really allows you to learn about and understand homelessness. The short videos profiling those who were once homeless and who have since been housed through the project, humanizes the subject by helping us understand their lives and the fact that, well, they aren’t really that different from you and me. They want to be safe, to be warm, to have dignity, to be housed. Check out the video of Simon from Montreal, and you will see what I mean.
The videos chronicling the experiences of caseworkers and landlords are equally enlightening. It is fantastic to learn from these videos that there are landlords all over the country who are willing to support Housing First and provide homes for people who are homeless. Many of these landlords like Jim the Housing Agent in Toronto seem to get much from their involvement, besides rent. They get a strong sense of fulfillment and an opportunity to participate in contributing to solutions to a seemingly intractable problem.
The videos here are interesting and well produced. They are also short and easy to consume, which is perfect for social media. So, one can visit the site and browse through them. One can also post them on Facebook (at under five minutes, they are perfect), Tweet them. If you are a teacher or professor, these are a great resource for your students. The videos can be used in community meetings, or to show your friends or family. Content like this is really the future of communication and of learning, and the partnership between the NFB and the At Home / Chez Soi project.
So why does any of this matter? For far too long we have dealt with homelessness by warehousing people in emergency shelters or worse still, throwing them in jail. After years of working with many others to address homelessness in Canada, I just feel that things need to change. And change in a big way. But things won’t change at all if people - and I’m talking about politicians, the news media and most importantly the general public – continue to think that everything is OK, or minimally, that the current system is the best we can offer. You know, “Times are tough, and we do provide people who are homeless with shelter and soup kitchens. And really, don’t most homeless people choose to be homeless after all?”.
We need to educate people on this front. The Here At Home series will play an important role in helping people across the country better understand homelessness, through hearing people who have experienced it talk about it. More importantly, the series helps all of us learn that there are real solutions to this seemingly intractable problem, and that Housing First works! The At Home / Chez Soi project shows that even when you take the most hard core, long term case; when you provide that person with a safe and decent place to live, when you treat them with respect and give them the supports they need, they stay housed. Nobody really wants to be homeless.
So visit the site, watch a video or two, and then share it. There are solutions to homelessness!
This article was originally posted on the National Film Board’s ‘Here at Home: In Search of the Real Cost of Homelessness blog.
We met Sayid after he was hospitalized due to an exacerbation of a pre-existing heart condition and foot pain related to long-standing diabetes and chronic exposure to dampness. His admission, the fourth in a six-month period, was largely related to his inability to take his medications as prescribed, lack of an appropriate diet, and limited access to a primary healthcare provider. Generally, he stayed clear of the healthcare system due to discomfort and fear after experiencing discrimination in numerous Emergency Departments and clinics. Furthermore, when he did seek medical attention, his healthcare providers would often suggest unrealistic treatment plans that did not take his unique set of social and living conditions into account.
In the United States, the National Healthcare for the Homeless Council (NHCHC) has established Clinical Practice Guidelines for care of the homeless to address the fact that chronic homelessness can significantly limit a patient’s ability to adhere to a plan of care. Had Sayid’s healthcare providers had access to evidence-based Canadian guidelines to assist them in the care of homeless patients within a local context, we believe that Sayid’s difficult experiences could have been prevented.
Sayid’s story is not uncommon. In fact, it is one of over 2000 that researchers have heard from homeless individuals across Canada who are enrolled in the At Home/Chez Soi Demonstration Project. This five-site (Toronto, Winnipeg, Moncton, Montreal and Vancouver), five-year, longitudinal study funded by the Mental Health Commission of Canada, is currently investigating ‘Housing First’ as an effective intervention for chronic homelessness. Through the provision of homes to 1000 study participants, we are seeing the way that safe and guaranteed housing is a more efficient and effective way to improve the lives of the homeless. In the Toronto arm of the study, we are conducting an analysis of the medical care that our study participants receive, in order to better understand the quality of healthcare provided to the homeless population.
Similar to Sayid, many homeless Canadians experience perpetual worsening of their physical and mental health for reasons that are, for the most part, preventable. Those who stay on the streets often lack access to clean water to take their medication or a safe place to store them. Further, most homeless individuals are unable to access nutritious meals to keep them healthy. When the homeless do receive care, the more frequent users of healthcare institutions report experiencing stigma and discrimination from healthcare providers and authorities. For others, accessing healthcare can be challenging for simple reasons, like having their health card stolen. Finally, up to 67% of the homeless have at some point been diagnosed with a mental illness, which itself is an obstacle to utilizing our universal healthcare system.
The NHCHC guidelines used in the United States are accessed by healthcare providers in a variety of settings and have become the nation’s go-to resource for homeless health provision and education. “The development of evidence-based, homeless-specific Adapted Clinical Guidelines has helped us to firmly establish that people experiencing homelessness have distinctive health care needs that require tailored interventions,” says NHCHC Executive Director, John Lozier. We feel that the homeless in Canada and the United States, and the healthcare systems in which they seek care, are sufficiently different in nature, such that a distinctly Canadian set of evidence-based guidelines will serve to improve the physical and mental health outcomes of our most vulnerable and marginalized. Differences in demographics (e.g. Aboriginal and immigrant populations), causes of mortality and morbidity and access to medical care, underscore a few of the reasons for the development of Canadian guidelines for the homeless.
Clinical Practice Guidelines specific for Canada’s homeless could lead to increased consistency, application and dissemination of best practices in care, thereby empowering healthcare providers to address the lives of these patients holistically, within a locally relevant context. “Increasingly, the social determinants of health are recognized as central to health status, but they are too often understood as phenomena well beyond the reach of healthcare practitioners,” adds John Lozier. Canadian-specific guidelines have the potential to lead to more effective implementation of preventative health measures, early identification of medical issues more commonly seen in homeless patients and more sensitive and less stigmatizing care by healthcare providers. For example, Canadian guidelines could assist healthcare providers in the management of less commonly seen presentations, such as the effects of Canada’s extreme weather patterns (e.g. heat, frostnip, frostbite, trench foot) on a population that is more exposed to the elements. Further, these guidelines could help practitioners by listing locally-relevant opportunities and resources that can potentially increase income and thereby reduce the effects of poverty on health (e.g. navigating provincial disability paperwork, special diet forms, local assistance programs for the homeless). These benefits are especially important given chronic homelessness’ heavy cost to Canadian society and the growing body of literature that supports the stigmatization of homeless populations in healthcare institutions.
As for Sayid, housing, supportive case management and attentive medical care provided through the study have contributed to improved physical and mental health, which has led to increased confidence and hope for the future. With approximately 300,000 homeless Canadians and 10,000 living on the streets without shelter on any given night, we hope that Sayid’s experience can become the norm, through ‘Housing First’.
Excellent Clinical Practice Guidelines have already been established for other vulnerable populations in Canada, such as for the care of immigrants and refugees. Initiatives like the At Home/Chez Soi Demonstration Project contribute to a larger body of knowledge aimed at addressing the challenges and obstacles that Canada’s homeless face on a day-to-day basis. We continue to seek solutions to end chronic homelessness. In the meantime, the development of evidence-based guidelines that address the unique needs of homeless people in Canada is a necessary step forward to improving the health of this marginalized population.
Naheed Dosani is a Family Medicine Resident Physician with the Department of Family and Community Medicine at the University of Toronto and is training at St. Michael’s Hospital. Follow Naheed on Twitter @NaheedD. Adam Whisler is a Research Coordinator for the At Home/Chez Soi Demonstration Project at the Centre for Research on Inner City Health at St. Michael’s Hospital. Follow Adam on Twitter @WhislerA.
This article was originally posted on the National Film Board’s ‘Here at Home: In Search of the Real Cost of Homelessness’ and Health Debate blogs.
It wasn’t so long ago that I would lament the lack of impact of research on the homelessness crisis in Canada. You often used to hear people say, “We don’t need research – we know what the problem is and we know what the solution is.”
I used to think, well, wrong on all counts. I could understand people’s impatience with the lack of progress, but really, I couldn’t think of any other crisis – whether it be HIV/AIDS, cancer or global warming – where people would see no need for research. What made this crisis so special?
The good news is that things have begun to change in a big way in the last several years. Communities across Canada are starting to see the value of research, and many researchers finding better ways to engage with service providers, communities, government and with people who have experienced homelessness in order to conduct research that contributes to solutions.
There are in fact many clear ways in which research can make an important contribution. First, there is conceptual research. This is research that inspires shifts in how we think about, understand and talk about the problem of homelessness. Research that poses the question, ‘can we and should we do things differently?’ Here I’m thinking of Hal Pawson’s work on homelessness prevention that has been so influential around the world, or Culhane and Metraux’ work on chronic homelessness in the United States. The recent CHRN Canadan Definition of Homelessness, produced through a collaborative process involving researchers, service providers, people in government and those with lived experience, is conceptual work in that it gives us clear language about how to think about homelessness.
The second kind of research that matters is instrumental research. This is research that helps us understand the effectiveness of our responses to homelessness. In other words, we can no longer just assume we are doing the right thing; we need to better understand, what works, why it works, for whom it works and under what conditions. There is growing recognition in the homelessness sector that we need to do more work on evaluating programs, using data management systems to understand the work at the systems level, and develop robust case study analyses of policy, systems and program level responses that will allow communities to share and adapt promising practices. The At Home / Chez Soi project (funded by the Mental Health Commission of Canada) is the most extensive research project on Housing First ever conducted, and is already showing amazing results. This research will help us really understand how Housing First works for different sub-populations, and in different urban and rural community contexts.
Finally, there is the symbolic use of research. That is, we can use research as evidence to help make the case for retaining what works, or what to do differently. Research can inform policy makers, practitioners, politicians and the general public about homelessness, its causes, conditions and solutions. A good example of this is the recent report: The Real Cost of Homelessness – Can we save money by doing the right thing?, which has inspired conversations across the country about the fact that while we might think that addressing homelessness through emergency services allows us to deal with this issue ‘on the cheap,' it is in fact really quite expensive, and not particularly effective.
So research does seem to matter after all. The challenge in making an impact is taking the evidence and having the learnings applied in real world situations. Communities like Calgary have become leaders in taking an evidence-based approach to solving homelessness, as has the Province of Alberta. All of this makes me optimistic that we can solve homelessness, especially if we draw from research evidence, and involve people from different sectors and walks of life working together to create solutions that treat people with dignity and give them hope.
About Stephen Gaetz
Dr. Stephen Gaetz is the Director of the Canadian Homelessness Research Network and an Associate Professor, Faculty of Education at York University.
CALL FOR PAPERS to the International Homelessness Research Conference: Advancing the Policy and Practice of Crisis Response Systems, to be held Monday, June 3 to Tuesday, June 4, 2013 at the University of Pennsylvania in Philadelphia, Pennsylvania. More details here.
What’s the best housing option for young people who become homeless? This is an important question, because when we design programs for homeless youth, we often create what I call “homeless services – junior”. We take the adult system – emergency shelters, etc., and just change the age limit. This is also true of some of our models of housing and support, whether transitional housing or Housing First. Sure, we understand that young people have different needs, and so we build in life skills, mentoring, training, etc. But the fundamentals of the program are all the same. For instance, it is typically the case that we impose time limits on how long someone can stay (one year residency, maybe eighteen months), and because of the pressure to transition youth to independence, a focus on education often takes a back seat to training and work.
So what do homeless youth need? When talking about how to address young people who are homeless, the best place to start is to think about what any young person needs – what my own sons need, for instance. Most of us take it for granted that growing into adulthood takes time, and that to get there, young people learn skills, behaviours, confidence and ways of being, one bit at a time. It's a time of learning, testing, succeeding and failing, and picking oneself up and dusting oneself off. In order to get there, youth need meaningful and respectful relations and encounters with adults and other young people. We know that we need to help young people stay in school for as long as possible, for in this economy, education and credentialism are more important than ever. The failure to complete high school means youth are less competitive in the labour market, as well as at a greater risk for future health problems and dependence on government supports. We know that growing into adulthood takes time. The days when you could leave home at seventeen, get a job and set yourself up in your own place are long gone. Because of changes to the economy (including a lack of full time entry level jobs that pay living wages), young people are staying at home longer and longer. A recent report from Statistics Canada showed that almost 43% of young people between the ages of 20 and 29 still live with their parents!
So, if we know all of this to be true, why do we treat young people so differently when they become homeless? Why does education get tossed out the window, and why the rush to living independently? Does it make sense to take traumatized youth and rush them into the responsibilities of adulthood, when they lack the necessary life skills, confidence, supports and the ability to compete in the job market? We need to rethink how we deal with homeless youth.
What if the goal of accommodation and supports was a transition to adulthood, rather than simply to independence? If we did that, things would look a lot different. One promising model that could be adapted in the Canadian context is the Foyer. This is a transitional housing model that is quite well developed in the United Kingdom and other European countries, and has been adapted and transformed in Australia. This is a model we can make work in Canada, by blending it with things we have learned about how to address youth homelessness here. The Canadian Homelessess Research Network report on Foyers (and accompanying toolkit) lays out in great detail what a Foyer is, what the research says about its effectiveness as a model of accommodation and supports, and how we can develop it here. What makes the Foyer an effective model of transitional housing is the following: first, it needs to be designed to meet the needs of developing adolescents and young adults. It is more than a roof over one’s head. Second, young people should be able to stay as long as they need to. Foyers in the UK typically have a two-year limit. Ideally, it should be open ended. After all, I don’t give my children a time limit on moving out. Third, education is at the centre of the Foyer model. While young people can also participate in training and employment, engagement in education will have the longest lasting impact on their lives. Fourth, the Foyer supports meaningful engagement. This means learning to establish solid relationships with adults and other youth, opportunities to get involved in the community, and to engage in activities – whether sports, arts, cooking etc. - that inspire and are fulfilling in their own right. The Foyer experience in the UK and Australia demonstrates that this model can be adapted and implemented in urban and rural areas, and that different models of housing can be used, whether a more institutional setting with multiple rooms, or a dispersed housing model.
The Foyer promises to change the way we respond to the needs of young people who become homeless. It is a model of accommodation and supports built to nurture the transition to adulthood in a safe, respectful and meaningful way. I would want nothing less for my own children.
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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.