Research Matters Blog

Homeless Hub
July 27, 2015
Categories: Topics

Case management refers to a collaborative and planned approach to ensuring that a person who experiences homelessness gets the services and supports they need to move forward with their lives. Originating from the mental health and addictions sector, case management can be used more broadly to support anyone experiencing homelessness. It is a comprehensive and strategic form of service provision whereby a case worker assesses the needs of the client (and potentially their family) and, where appropriate, arranges, coordinates and advocates for delivery and access to a range of programs and services designed to meet the individual’s needs. The National Case Management Network of Canada (NCMN) defines case management as a:

 “collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources. Case management supports the client’s achievement of safe, realistic, and reasonable goals within a complex health, social, and fiscal environment.” (National Case Management Network of Canada, 2009: 7) 

Activities of case managementA client-centered case management approach ensures that the person who has experienced homelessness has a major say in identifying goals and service needs, and that there is shared accountability. The goal of case management is to empower people, draw on their strengths and capabilities, and promote an improved quality of life by facilitating timely access to the necessary supports, thus reducing the risk of homelessness and/or enhancing housing stability. 

Case management, well established in social work and health care, has many different approaches and practices. Case management can be short term (as in Critical Time Intervention) or long term and ongoing, dependent upon an identified need for crisis intervention related to problematic transitions, or for supports around chronic conditions. Critical Time Intervention (CTI) models are key to early intervention practice in that they are designed to prevent recurrent homelessness and help people transition to independence. This is achieved through:

 “strengthening the individual’s long-term ties to services, family, and friends; and by providing emotional and practical support during the critical time of transition. An important aspect of CTI is that post-discharge services are delivered by workers who have established relationships with patients during their institutional stay.” (Critical Time Intervention Website

Individuals with more complex, severe and persistent health, mental health and addictions challenges may require more intensive case management through Assertive Community Treatment (ACT) teams. In the ACT model, a multidisciplinary team from the community where the individual lives (rather than in an office-based practice or institutional setting) provides case management. The team involves psychiatrists, family physicians, social workers, nurses, occupational therapists, vocational specialists, peer support workers, etc., and is available to the patient/client 24 hour a day, 7 days a week. 

A case management approach, then, necessarily works best within a system of care, where links are made to necessary services and supports, based on identified client need. That is, once a person becomes homeless, or is identified as being at risk, they are not simply unleashed into the emergency services sector. An intake process is followed, risks are identified, goals are established and plans are put in place. Individuals in need, therefore become ‘clients’ not of specific agencies, per se, but rather, of the sector. They are supported from the moment they are identified as (potentially) homeless, right through to the solution stage, and then after they have secured housing. 

Case management, of course, requires a willingness on the part of the individual to participate, and development of a potentially therapeutic relationship may take time. When people become homeless and have very weak links or engagement with homelessness services, schools or other supports, and are only accessed through outreach and/or day programs, a period of relationship and trust building may be required before case management can be usefully implemented. 

In reviewing case management as a key component to ending homelessness, Milaney identified it as a strengths-based team approach with six key dimensions:

  1. Collaboration and cooperation – a true team approach, involving several people with different backgrounds, skills and areas of expertise;
  2. Right matching of services – person-centered and based on the complexity of need;
  3. Contextual case management – Interventions must appropriately take account of age, ability, culture, gender and sexual orientation. In addition, an understanding of broader structural factors and personal history (of violence, sexual abuse or assault, for instance) must underline strategies and mode of engagement;
  4. The right kind of engagement – Building a strong relationship based on respectful encounters, openness, listening skills, non-judgmental attitudes and advocacy;
  5. Coordinated and well-managed system – Integrating the intervention into the broader system of care; and
  6. Evaluation for success – The ongoing and consistent assessment of case managed supports.

There are a number of useful resources to help service providers deliver case management in the homelessness sector. The Calgary Homeless Foundation has developed a report called “Dimensions of Promising Practice for Case Managed Supports in Ending Homelessness”. In Australia, the government has a dedicated website with a large number of resources for doing case management with people who have experienced homelessness. Finally, the National Alliance to End Homelessness also has a number of resources dedicated to this topic.

Diagram above is from the Calgary Homeless Foundation's report “Dimensions of Promising Practice for Case Managed Supports in Ending Homelessness”.

Canadian Observatory on Homelessness/Homeless Hub: York University
July 24, 2015
Categories: Ask the Hub

Ryan W. asked this question via our latest website survey.

While seniors aren’t a majority in the homeless population, “there are many whose social marginality, lack of financial resources, or chronic ill health causes them to be seriously at risk of homelessness” (Robertson & Greenblatt, 1992). In Canada, these numbers are increasing. In 2013, there were four times as many seniors experiencing homelessness in Toronto as there was in 2009. Despite Canada having low old-age poverty rates in comparison to other G20 countries, the OECD reports that it increased while other countries’ rates fell.

""Causes of homelessness in old age

The National Coalition for the Homeless (2009) cited “poverty and the declining availability of affordable housing among certain segments of the aging” as primary causes of homelessness. Physical and mental health issues, social marginalization/lack of social support and loss of family/caregivers are also often among cited causes.

Though the factors that lead to homelessness are the same for seniors as they are for anyone (a mix of structural, systemic and individual/social), there are some gendered differences in how seniors become homeless. A 2004 Toronto study found that older women are more likely to become homeless due to primarily family-related crises, while older men tend to become homeless due to primarily a lack of employment.

The 2010 OECD report also highlights these differences. Senior women are more likely to have worked part-time, low-wage and/or temporary jobs – which can lead to poverty and homelessness. This especially affects senior women who are separated or divorced.

Another issue cited by the OECD is that seniors in Canada depend more heavily on private capital (assets, private pensions, etc.) to live than most other OECD countries. This leaves all low-income seniors vulnerable, as they are less likely to have such resources.

Isolation and sudden changes in circumstances (such as illness) are also contributors to senior homelessness. With such a wide array of causes, it is impossible to identify pathways to senior homelessness as being clear-cut.

Risks of being homeless in old age

Older people experiencing homeless are in what Kellogg and Horn (2013) call “double jeopardy:”

Aged persons who are isolated, live alone, and lack economic stability and family or social supports are at great risk for becoming homeless. Precipitating factors may include death of a spouse or a caregiver who provided support, job loss, familial estrangement, domestic violence, and mental illness. Once housing is lost, lack of general resources, lack of social supports, and declining health make it extremely difficult for low-income elderly men and women to relocate into other adequate housing…Not only do they face all of the problems that homeless people face regardless of age but they also encounter the problems that elderly people face regardless of housing status.

In the past, seniors experiencing homelessness have been neglected in terms of researching and creating services that are specific to their unique needs, but this has changed in recent years. We are still, unfortunately, behind when it comes to fully including seniors in planning services and interventions in our policies (see Barken et al, 2015).

The impact of homelessness during old age is often drastic and complicated. The Homeless Adult Research Project in Toronto reported some unfortunate findings:

  • “Almost 70 percent of older homeless people reported first becoming homeless between the ages of 41 and 60.
  • Most of the older adults currently at risk for homelessness had been homeless at least one time in their lives.
  • Almost 60% of the chronic homeless rated their health as poor or fair; almost 50% of the new homeless rated their health as good, very good, or excellent. In the general population, 80% of older adults rate their health as excellent.
  • According to the SF-12 (a standardized measure of health status), homeless older adults are physically older than their chronological age, and are in worse physical health than the general older population.”

Addressing senior homelessness

One Ontario case study of 129 service users (who were older and experiencing homelessness) “…confirmed the value of a continuous caring relationship with an identified provider and the delivery of a seamless service through coordination, integration and information sharing between different providers.” The study also underscored larger systemic failures that act as barriers to the program, which included “limited housing options available; limited income supports; and lack of coordinated, accessible community health and support services.”

Woolrych and Gibson made some recommendations on how we can work towards preventing and addressing senior homelessness:

  • Funding based on needs rather than age (young people are frequently targeted for employment and substance use programs, but these do not benefit seniors, who look at their future differently)
  • Providing affordable housing that meets seniors’ needs: supported living services, fulfills sense of purpose and community – HEARTH is an example of successful service-enriched housing
  • Creating health services that properly address complex physical and mental health needs
  • Address multiple kinds of abuse (physical, sexual, financial)
  • Education on available resources for seniors
  • More transitional housing

Not all services or solutions will work for all seniors experiencing homelessness. One population that requires additional consideration is Aboriginal seniors, who must cope with the challenges of aging as well as the ongoing legacy of colonization and racism in this country. Beatty and Berdahl (2011) recommend establishing long-term care facilities in major prairie cities and on reserves for Aboriginal seniors; as well as funding initiatives for Aboriginal caregivers. As I wrote before in a blog post about senior women, “more publicly funded long-term care for all Canadian seniors—like those created in Sweden, Denmark, and Iceland—would be beneficial for all, and would help relieve some of the financial stress on our seniors.”

This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at thehub@edu.yorku.ca and we will provide a research-based answer.

York University; Canadian Observatory on Homelessness/Homeless Hub
July 22, 2015

This week’s infographic, created by World Hepatitis Day, takes a look at using harm reduction as a tool to reduce the spread of hepatitis. Hepatitis is a disease characterized by the presence of inflammatory cells in the liver. While it is possible for hepatitis to occur with limited, and even no symptoms, hepatitis often leads to other diseases (ex: jaundice). The term harm reduction can be defined as “an approach or strategy aimed at reducing the risks and harmful effects associated with substance abuse and addictive behaviours for the individual, the community and society as a whole.”

The infographic states that globally 67% of people who inject drugs are infected with hepatitis. Upwards of 10 million people who inject drugs worldwide have hepatitis B or C. Vaccination rates of hepatitis B among people who inject drugs are lower than in the general population. The infographic also states that stigma and discrimination of people who use drugs stop them from getting tested and treated. Individuals and families that are living in homelessness are a perfect example of individuals who face stigma and discrimination in how health services are both structured and delivered.

In Toronto, homeless individuals are 29 times more likely to have the hepatitis C virus compared to members of the general population. Over the long-term, hepatitis C can lead to long-term kidney failure and kidney cancer. Hepatitis C is primarily spread through intravenous drug use and the sharing of needles. Other homeless populations across Canada are also likely to have higher rates of hepatitis B and C compared to the general population.

Harm Reduction

Rather than condemning substance use, a harm reduction approach is focused on reducing the risks associated with using drugs. The approach is nonjudgmental, and is meant to “meet people where they are at”. Programs built into such an approach may include the facilitation of peer support groups for drug users, needle distribution as well as supervised injection sites.

Insite, located in the Downtown Eastside neighbourhood of Vancouver and the only legalized supervised drug injection site in North America, is an example of a program that takes such an approach. The neighbourhood has been considered the centre of an injection drug epidemic, and was reported to be home to 4700 injection drug users in 2000. The results of the Insite program, which opened in 2003, have been largely positive. There have been zero overdose death reported at the facility, a 78% decrease in new reported cases of HIV among people who inject drugs in the local area between 2002-2011 and a 55% decrease in new reported cases of Hepatitis C over the same time period.

There is a great deal of evidence that speaks to the effectiveness of harm reduction, both nationally and internationally. Programs and communities in Canada have been successful in reducing health risks (ex: reducing rate of infection for Hepatitis) for community members through the adoption of a harm reduction approach. However, we continue to allow misunderstandings about this innovative strategy, and misplaced fear and prejudice against drug users, to act as a barrier against wider adoption of harm reduction.

PREVENT HEPATITIS: HARM REDUCTION

Canadian Observatory on Homelessness/The Homeless Hub
July 21, 2015

COH's PiT Count ToolkitThe Canadian Observatory on Homelessness has launched an early release of its Point-in-Time Count Toolkit. The Toolkit – supported, in part, by the Government of Canada’s Homelessness Partnering Strategy (Employment and Social Development Canada) and the Social Sciences and Humanities Research Council of Canada - coincides with an exciting and timely announcement from the Homelessness Partnering Strategy (HPS).

The HPS will support designated communities to participate in a Coordinated PiT Count in the first sixty days of 2016. The HPS Coordinated Count is a significant opportunity to work towards a national picture of homelessness in Canada.

Our Toolkit – building on the work of the National Homeless Count Research Advisory Team - provides communities with the information and the resources they need to participate.

What is a PiT Count?

There are many ways to conduct a PiT Count; communities across Canada have developed their own approaches. But most simply, a PiT Count is a strategy to count the number of individuals experiencing homelessness at a single point in time.

Over a single point in time – usually a night - communities deploy volunteers to the street to locate, and survey, individuals who are experiencing homelessness. During that same period, volunteers are deployed to shelters, and other overnight facilities, to count and survey those that are staying the night.

At the end of the PiT Count, communities have two types of information: first, estimates of the number of people that are sleeping outside and in shelters; second, information about those that were surveyed. This includes information such as gender, age, veteran status, length of homelessness and service use.

What are the benefits?

Point-in-Time Counts allow communities to better understand the nature and extent of homelessness and the characteristics of the homeless population. PiT Counts support better planning, and when done on more than one occasion, allow communities to assess their progress in reducing, and ultimately ending, homelessness. 

PiT Counts are not new to Canada; many communities across the country have conducted at least one. These communities have used their PiT Count data to establish baselines of homelessness, monitor progress over time and develop community-wide plans to end homelessness; the local benefits of PiT Counts are proven.   

However, the benefits of PiT Counts are not easily realized at a provincial, territorial or national level. Communities use different approaches; consequently, PiT Count data is difficult to aggregate. There is a growing recognition that provincial, territorial and national coordination is required to end homelessness; however, we need accurate data to inform the effort.

In 2016, this will be the first effort to coordinate PiT counts in communities across Canada. It builds on the work done by Alberta’s 7 Cities on Housing and Homelessness, which conducted a coordinated PiT Count with aligned methodologies in 2014. As a result, they have the first-ever combined baseline of homelessness across the 7 Cities. 

The purpose of the COH PiT Count Toolkit

The COH PiT Count Toolkit is designed to support communities participating in the 2016 Coordinated Count to plan, implement and learn from their PiT Counts. An important goal of the Toolkit is to encourage alignment across communities. The COH Toolkit provides a set of resources to help you adapt the common approach to your local needs and circumstances.

Over the next few months, we will continue to update the PiT Count Toolkit. Refer to the Toolkit Release Schedule for a full list of forthcoming resources. If you would like to be notified when new tools and templates are added, you can subscribe to updates here

In the meantime, the COH is here to help. The PiT Count Toolkit and the HPS Guide to Point-in-Time Counts in Canada contain more than enough information to get started but communities are encouraged to contact me, COH PiT Count Coordinator for information and guidance.

Homeless Hub
July 20, 2015
Categories: Topics

Feasibility Study of the Social Enterprise Intervention with Homeless Youth - Homeless Hub Research SummaryWhile there is no commonly agreed upon definition for a social enterprise there are several shared key qualities. Social enterprises are revenue-generating businesses but they have a focus on creating socially-related good. This mission is central to a social enterprise, particularly for non-profit/community-based entities. For these organizations, “profits” are generally reinvested in growing the business or supporting other key projects. In all cases, social enterprises don’t give money to shareholders or individuals as “profit” (employees will be paid as part of the business plan). 

Social enterprises in the community sector often hire people who have been marginalized from the mainstream job market. This could include people facing mental health or addictions issues, people with disabilities, people living in poverty, people experiencing homelessness/poor housing or youth. In addition to job skills, a social enterprise also tends to provide other support services including life skills, counselling and access to other services provided by the organization. 

There are a wide variety of social enterprise activities used in the community non-profit sectors include arts and crafts, courier services, catering businesses, laundry services, print shops, restaurants, thrift stores etc. 

See how the Train for Trades employment program for at-risk and homeless youth is moving to become a self-sustaining social enterprise in the Youth Employment Toolkit.

Pages

Recent Tweets

Content on this site is licensed under a Creative Commons Attribution Non-Commercial No Derivatives License

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.