Abstract
Approach: The high-needs supportive care housing program (SCH) has created a comprehensive care environment that is anchored in the Housing First model approach to support a client cohort of six women. The SCH supports women who were previously homeless and who have a history of homelessness. Referrals into the program are made from Street Haven (SH) shelter programs. The key goal is to keep clients stably housed despite their medical, mental health and social care need. An intensive case management approach ensures all the health and social care needs of the clients are addressed with the aim of keeping clients stably and healthily housed. Through integrated health and social care (IHSC) partnerships, the program ensures that clients complex and chronic medical and mental health needs are being addressed in the community outside of acute care settings. Clients are all attached to a primary healthcare physician from nearby community health centres and family health teams (FHT). They are attached to hospital specialists. Clients are attached to community mental health programs and psychiatric services through FHTs. The case management ensures healthcare navigation. Medication needs are addressed with the local pharmacists. The SCH worker ensures that all clients meet all medical appointments.The program also ensures that social care needs are addressed. Liaison with the Ontario Disability Assistance Program is maintained. Liaison with housing benefits is established to ensure that supports exist to keep clients stably housed. Integration across all SH programs and services in training supports to enhance the access to socio-cultural programming.Who? In developing a comprehensive supportive care housing program, an IHSC approach was undertaken to ensure that wrap-around and holistic care can be provided to these clients. The success of this program relies on partnerships with community-based healthcare partners including primary health care that include local community health centres and family health teams, specialists affiliated with local hospitals, community care for personal support staff, and mental health and addictions providers. In addition, clients are connected to social assistance providers in the community including Ontario Disability Assistance Program social services worker.SH has also integrated care within its organization that further supports the stability of clients. In addition to providing intensive case management through its supportive care housing manager, clients are offered the SH training and socio-cultural programming offered across the agency. Clients are involved in the co-design and continuous improvement of the SCH program by providing feedback.
Results: Despite the fact that all clients have a diagnosis of schizophrenia, all clients are able to co-exist collegially and build deep friendships with each other. There have been very few crisis episodes, clinically and from a mental health perspective. There is minimal avoidable acute care utilization. Moreover, clients are aging in place. Lastly, clients have developed a strong social care network with each other and with the SH team, thereby minimizing social isolation.
Implications: In order for supportive care housing serving homeless women to be successful, it must operate from a Housing First model using an integrated health and social care approach. The focus must include creating a safe housing environment that provides wrap around health and social care services with intensive case management as the key to ensuring a social determinants of health lens to supportive care housing for marginalized and vulnerable women. A home-like environment that has created a small community of women who are able to co-exist socially and build a strong social network is a success factor . In response to the Toronto housing crisis, SH seeks to introduce more supportive care housing for homeless women. This program success will be replicated in future SCH.