Evidence at a glance: Housing First and community integration

Housing First (HF) is an evidence-based approach to ending homelessness among people with mental illness, other complex needs (e.g., addictions, chronic health issues), and long periods of homelessness.1 HF combines rent supplements with support, typically in the form of Assertive Community Treatment or Intensive Case Management.2 Rather than providing “treatment first” to ensure that people are “housing ready”, the focus of HF is to provide people with housing immediately. A key principle of HF is community integration.

Read the resource below or download the PDF.

What is community integration?

Community integration has its roots in the disability rights movement, including people with physical, developmental, and psychiatric disabilities.3 The rallying cry of this movement was and continues to be “independent living.” Historically, people with disabilities were and continue to be placed in group living facilities, be they large institutions or mini-institutions in the community.

In their research, Aubry and Myner4 proposed that community integration consists of three components:

  1. Physical integration is the extent to which people participate in community activities outside of their home.
  2. Psychological integration is the extent to which people experience a psychological sense of community and feel an emotional connection to people in their neighbourhood.
  3. Social integration is the extent to which people have contact with neighbours.

HF strives to promote these three aspects of community integration by helping people who are homeless move into regular rental housing scattered throughout the community. While HF strives to promote community integration, overall the research findings about its effectiveness this area are mixed:5

  1. Research has shown that choice and scattered-site housing are positively associated with psychological and social integration.6
  2. Outcome research on HF has tended not to find improvements in community integration for HF participants relative to those in “usual treatment”.7, 8 Two exceptions are studies by Patterson et al.9 in Vancouver and Aubry et al.10 in Moncton. In both studies, HF recipients showed greater improvement in psychological integration than individuals receiving treatment-first approaches.
  3. There is evidence that people with mental illness residing in different types of housing in the community score lower on social integration, but not physical or psychological integration, than community participants without a history of mental illness.4, 11

In the context of these mixed findings, focus on enhancing HF support to more effectively facilitate community integration is needed. Based on their recent review, Marshall et al.11 have argued that more targeted psychosocial interventions that include peer support show promise and should be incorporated into HF programs.

How can you use this evidence?

  1. Congregating formerly homeless people into one setting works against community integration by creating new mini-institutions in the community. Scattered-site apartments with rent supplements can promote community integration and should be made available for helping people who are chronically homeless to leave homelessness.12
  2. In New York City, the HF approach began by listening to the preferences of people who were homeless. When communities conduct Point-in-Time counts (i.e., 24-hour census) of the homeless population), they should include questions about the preferences of people for housing and support.
  3. HF programs should be expanded and adequately resourced with sufficient rent supplements, well-trained staff and intensive support services, including Assertive Community Treatment.13
  4. HF programs should incorporate strategies to promote community integration, like peer support.11

This resource was written by Dr. Geoff Nelson and Dr. Tim Aubry (2020, July), co-leads of the Ontario Housing First Regional Network Community of Interest. This summary is not a full or comprehensive evidence review of the topic, but highlights of the evidence from key articles and subject matter experts on housing first and homelessness. The Ontario Housing First Regional Network Community Interest is supported by Evidence Exchange Network, which is part of the Provincial System Support

Program at the Centre for Addiction and Mental Health.

Additional resource: Rain City Housing First Social and Community Integration Video (8 minutes, 26 seconds) 

References

  1. Aubry, T., Nelson, G. & Tsemberis, S. (2015). Housing First for people with severe mental illness who are homeless: A review of the research and findings from the At Home-Chez Soi demonstration project. Canadian Journal of Psychiatry, 60, 467–474.
  2. Tsemberis, S. (2015). Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Center City, MN: Hazelden Publications.
  3. Carling, P. J. (1995). Return to Community: Building Support Systems for People With Psychiatric Disabilities. New York: The Guilford Press.
  4. Aubry, T. & Myner, J. (1996). Community integration and quality of life: A comparison of persons with psychiatric disabilities in housing programs and community members who are neighbours. Canadian Journal of Community Mental Health, 15 (1), 5–20.
  5. Marshall, C.A., Boland, L., Westover, L.A., Marcellus, B., Weil, S. & Wickett, S. (2020). Effectiveness of interventions targeting community integration among individuals with lived experience of homelessness: A systematic review. Health and Social Care in the Community. Available: https://doi.org/10.1111/hsc.13030. Accessed July 29, 2020.
  6. Gulcur, L., Tsemberis, S., Stefancic, A. & Greenwood, R. (2007). Community integration of adults with psychiatric disabilities and histories of homelessness. Community Mental Health Journal, 43, 211–228. Available: https://doi.org/10.1007/s10597-006-9073-4. Accessed July 29, 2020.
  7. Aubry, T., Goering, P., Veldhuizen, S., Adair, C.E., Bourque, J., Distasio, J. et al. (2016). A multiple-city RCT of Housing First with Assertive Community Treatment for homeless Canadians with serious mental illness. Psychiatric Services, 67, 275–281. Available: https://doi.org/10.1176/appi.ps.201400587. Accessed July 29, 2020.
  8. Stergiopoulos, V., Hwang, S.W., Gozdzik, A., Nisenbaum, R., Latimer, E., Rabouin, D. et al. (2015). Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: A randomized trial. JAMA. 313, 905–915. Available: https://doi.org/10.1001/jama.2015.1163. Accessed July 29, 2020.
  9. Patterson, M.L., Monaruzziman, A. & Somers, J.M. (2014). Community participation and belonging among formerly homeless adults with mental illness after 12 months of Housing First in Vancouver, British Columbia: A randomized controlled trial. Community Mental Health Journal, 50, 604–611. Available: https://doi.org/10.1007/s10597-013-9672-9. Accessed July 29, 2020.
  10. Aubry, T., Bourque, J., Goering, P., Crouse, S., Veldhuizen, S., LeBlanc, S. et al. (2019). A randomized controlled trial of the effectiveness of Housing First in a small Canadian city. BMC Public Health, 19 (1), 1–14.
  11. Yanos, P.T., Stefancic, A. & Tsemberis, S. (2011). Psychological community integration among people with psychiatric disabilities and nondisabled community members. Journal of Community Psychology, 39, 390–401. Available: https://doi.org/10.1002/jcop.20441. Accessed July 29, 2020.
  12. Nelson, G., & Aubry, T. (2017). A Portable Housing Benefit as an Indispensible Component of Ending Homelessness in Canada. Toronto, ON: Evidence Exchange Network. Available: http://eenet.ca/initiative/housing-first-communityinterest#about. Accessed July 29, 2020.
  13. Nelson, G. & Aubry, T. (2018). Assertive Community Treatment (ACT) and Housing First in Canada. Toronto: EENet, Ontario Housing First Regional Community of Interest. Available: http://eenet.ca/resource/policy-brief-assertivecommunity-treatment-act-a.... Accessed July 29, 2020.

The Ontario Housing First Regional Network Community of Interest (OHFRN-COI) is intended to assist communities across Ontario to develop, evaluate, and improve Housing First (HF) programs based on the Pathways model tested, adapted, and shown to be effective in the At Home/Chez Soi Demonstration Project. This CoI is supported by Evidence Exchange Network (EENet), which is part of the Provincial System Support Program (PSSP) at the Centre for Addiction and Mental Health.