Generating Evidence for a Support Package to Stabilize Youth Trajectories Out of Homelessness

Generating Evidence for a Comprehensive Support Package to Stabilize Youth Trajectories Out of Homelessness: A Tertiary Prevention Strategy

This project builds upon initial proof of concept work examining the optimal set of supports for youth who have recently exited homelessness - an intervention comprised of mental health and peer supports alongside transitional case management. This collaborative model will be tested as a proof-of-concept in Thunder Bay with Indigenous youth and a trial will be conducted in Toronto to optimize and determine the effectiveness of the existing model of support.

Study Overview

• Status: Completed
• Conditions: Homelessness; Youth
• Intervention / Treatment: Behavioral: Transitional Case Management Only; Behavioral: HOP-C

Detailed Description

In response to the challenges outlined above, and with the support of a grant from the Ontario Ministry of Child and Youth Services, the investigators developed and tested a tertiary prevention strategy called the Housing Outreach Program Collaborative (HOP-C) which launched in the summer of 2015. In this approach the investigators focused on collaborations and interventions that have the greatest potential to be effective with this population. The investigators brought together partners from a number of sectors in the GTA and have tested a 3-pronged set of supports (intervention described in detail in the methods):

• Transitional Case Management
• Mental Health Interventions: Group, individual, family
• Peer Support This is an intensive, 6-month critical time intervention - one that jointly addresses many points of vulnerability (mental health crises, housing instability, justice involvement) while fostering resilience and connection with resources in employment, education and training domains. It is unique in both content comprehensiveness and integrated process of delivery. Also important was the development of a collaborative and responsive partnering process, to facilitate effective organizational interfaces and seamless service integration so participants can experience a tailored and coherent set of supports. With CAMH, the Centre for Mindfulness Studies, Covenant House, LOFT, and SKETCH at the service level and the Wellesley Institute leading evaluation, the investigators have carefully attended to a collective impact framework.

This initiative has proven feasible and is demonstrating good outcomes - with excellent youth engagement, reports of lower social isolation, improved mental health, and engagement with resources, and spin-off benefits of closer collaboration between organizations. The investigators successfully met the target of youth engagement, with a total of 31 youth participating, minimal attrition (n=2), and the investigators observed no indications that HOP-C resulted in risk of any form, both with respect to the intervention itself and the mixed methods research methodology. This promising feasibility work formed the foundation from which the investigators were successful in obtaining a grant from the Local Poverty Reduction Fund to support the study described in this proposal.

Current Project Determine through a randomized trial in Toronto if the positive outcomes the investigators are observing are due solely or primarily to transitional case management and if the additional peer and mental health components are necessary.

Engaging in intensive, tertiary prevention shows clear promise in disrupting a cycle of poverty and marginalization at a critical time - if proven and scaled a key driver of chronic homelessness would be addressed.

Research Questions The objective of this two-part project is to examine the effectiveness and transferability of the Housing Outreach Program-Collaboration (HOP-C) transitional intervention. HOP-C has proven to be feasible with promising outcomes in the Toronto proof-of-concept work currently underway.

1. Are the benefits of the complex HOP-C intervention with all components in place greater than transitional case management in isolation?

• It is hypothesized that the full model will provide benefit in domains of housing stability, mental health, and quality of life that are significantly greater than case management alone.

The investigators have data in hand from their recent national work in the area which provides data on 'treatment as usual' or the outcomes that attend typically available supports. The proposed trial will unpack benefit and be essential in economic and viability arguments to be made going forward.

• Study Type: Interventional
• Enrollment (Actual): 65
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Ontario
    • Toronto, Ontario, Canada, M5T 1R8
      • Centre for Addiction and Mental Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 26 years (ADULT, CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• between the ages of 16 and 26
• have obtained secure housing in a time period up to 12 months previously

Exclusion Criteria:

• none

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: SINGLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Transitional Case Management Only; Participants in this arm will be provided with a transition-focused community support worker who will assist in areas ranging from general support and encouragement to assistance in navigating relevant systems. They will have weekly contacts with participants by phone, informal contact via text and email, and at least twice per month will visit the participant where they are residing. It is expected that all participants will engage a community support worker. The transitional case manager hired into this role will be highly experienced in case management for youth.	Behavioral: Transitional Case Management Only; Participants in this arm will be provided with a transition-focused community support worker who will assist in areas ranging from general support and encouragement to assistance in navigating relevant systems. They will have weekly contacts with participants by phone, informal contact via text and email, and at least twice per month will visit the participant where they are residing. It is expected that all participants will engage a community support worker. The transitional case manager hired into this role will be highly experienced in case management for youth.
EXPERIMENTAL: Full HOP-C Service; Service provision will be provided by Loft and Covenant House for the transitional case management component, the peer component will be supported through Sketch Arts, and the mental health component will be provided by a post-doctoral fellow clinical psychologist and a mindfulness therapist from the Centre for Mindfulness Studies, supervised by Dr. Sean Kidd.	Behavioral: HOP-C; Service provision will be provided by Loft and Covenant House for the transitional case management component, the peer component will be supported through Sketch Arts, and the mental health component will be provided by a post-doctoral fellow clinical psychologist and a mindfulness therapist from the Centre for Mindfulness Studies, supervised by Dr. Sean Kidd.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Housing	Participants coded in a binary manner as having gained or sustained housing (binary positive) or lost (binary negative) based on assessment of the participant's trajectory from baseline to 6 months.	Change from Baseline to 6 months
Employment/Education	Participants coded in a binary manner as having gained or sustained education or employment (binary positive) or lost (binary negative) based on assessment of the participant's trajectory from baseline to 6 months.	Change from baseline to 6 months
Mental Health	Participants coded in a binary manner as having gained or sustained mental health status without crises (binary positive) or experienced a crises that impacted major life domains (binary negative) based on assessment of the participant's trajectory from baseline to 6 months.	Change from baseline to 6 months
Housing Security Scale	The Housing Security Scale contains 12 items on a 5 point likert scale (Frederick et al., 2014). Scores range from "strongly disagree" (minimum = 1) to "strongly agree" (maximum = 5). Higher scores indicate better outcomes. Mean item range is 1-5 with pre-post difference reported.	Change from Baseline to 6 months
Housing Security Scale (Subjective Housing Stability Subscale)	The Housing Security Scale contains a 4 item subscale that measures subjective housing satisfaction and perception of housing stability (Frederick et al., 2014). Scores range from "strongly disagree" (minimum = 1) to "strongly agree" (maximum = 5). Higher scores indicate better outcomes with a mean range of 1-5 with pre-post change reported.	Change from Baseline to 6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mental Health Continuum - Short Form	Mental Health Continuum - Short Form assess mental health and addictions by measuring emotional, psychological and social well-being. It contains 14 items on a 6 point scale ranging from at minimum "never" (0) to, at maximum, "every day" (5). Higher scores indicate better outcomes. Range is 0-5 (means) with pre-post differences reported.	Change from baseline to 6 month
Cognitive and Affective Mindfulness Scale	Cognitive and Affective Mindfulness Scale Revised was used to measure mindfulness and has demonstrated acceptable reliability (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007). It contains 10 items. The minimum score is "rarely/Not at all" (1) and the maximum score is "almost always" (4). Higher scores indicate better outcomes with a mean item range from 1-4 with pre-post mean change reported.	Change from baseline to 6 months
Community Integration Scale	Behavioural and psychological aspects of community integration was examined using Community Integration Scale The scale contains 7 dichotomous questions with higher scores indicating greater community integration (better outcomes). Mean item range is 0-1 with mean change reported.	Change from baseline to 6 months
Community Integration Measure	Behavioural and psychological aspects of community integration were examined using the Community Integration Measure. The measure contains 6 items scored on a 5 point scale ranging from, at minimum, "always disagree" (1) to, at maximum, "always agree" (5). Higher scores indicating better outcomes with an item mean range from 1-5 with mean pre-post differences reported.	Change from baseline to 6 months
Resilience Scale	Resilience will be measured using the 10-item Resilience Scale. Each item score ranges from, at minimum, "Not true at all" (0) to, at maximum, "True nearly all the time" (4) with higher scores indicating better outcomes. Mean item range is from 0-4 with pre-post change in means reported.	Change from baseline to 6 months
Adults Hope Scale	Adult Hope Scale, a cognitive measure of hope, was employed. This self-report questionnaire contains 8 questions that are each scored on an 8 point Likert scale with scores ranging from "Definitely False" to "Definitely True". Higher scores indicate better outcomes. Mean item range is minimum 1 to maximum 8 with pre-post mean differences reported.	Change from baseline to 6 months
GAIN Short Screener (CAMH Modified)	Mental health (and addictions) was measured using the Global Assessment of Individual Needs Short Screener, which includes 22 items scored on a 5 point scale ranging from "never" (0) as the minimum score and "past month" (4) as the maximum score. Higher scores indicate worse outcomes. Mean item range is 0-4 with pre-post mean change reported.	Change from baseline to 6 months
Medical Outcomes Study (MOS) Social Support Survey	We used a modified version of the Medical Outcomes Study Social Support Survey to measure social support. It is a 15-item 5-point Likert-type scale. The maximum score is "all of the time" (5) and the minimum score is "none of the time" (1). Higher score indicates better outcome. Item mean range is 1-5 with pre-post mean difference reported.	Change from baseline to 6 month
World Health Organization Quality of Life Scale - BREF	The brief World Health Organization Quality of Life Scale - BREF contains 26 items, each scored from 1 to 5 with various labels for each score (e.g. 1= "very poor" for item 1 and 1= "very dissatisfied" for item 2). Higher scores indicate better outcomes with a mean item range of 1-5 with pre-post mean change reported.	Change from baseline to 6 months

Collaborators and Investigators

• Sponsor: Centre for Addiction and Mental Health

Publications and helpful links

General Publications

• Research design: qualitative, quantitative and mixed methods approaches Research design: qualitative, quantitative and mixed methods approaches Creswell John W Sage 320 pound29 0761924426 0761924426 [Formula: see text]. Nurse Res. 2004 Sep 1;12(1):82-83. doi: 10.7748/nr.12.1.82.s2.
• Skevington SM, Lotfy M, O'Connell KA; WHOQOL Group. The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004 Mar;13(2):299-310. doi: 10.1023/B:QURE.0000018486.91360.00.
• Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003 Apr;84(4):822-48. doi: 10.1037/0022-3514.84.4.822.
• Altena AM, Brilleslijper-Kater SN, Wolf JL. Effective interventions for homeless youth: a systematic review. Am J Prev Med. 2010 Jun;38(6):637-45. doi: 10.1016/j.amepre.2010.02.017.
• Barber CC, Fonagy P, Fultz J, Simulinas M, Yates M. Homeless near a thousand homes: outcomes of homeless youth in a crisis shelter. Am J Orthopsychiatry. 2005 Jul;75(3):347-55. doi: 10.1037/0002-9432.75.3.347.
• Boyatzis, R. E. (1998). Transforming Qualitative Information: Thematic Analysis and code Development. Thousand Oaks, California: Sage.
• Bryman, A. (2006). Integrating quantitative and qualitative research: How is it done? Qualitative Research, 6, 97-113.
• Cloitre M, Courtois CA, Charuvastra A, Carapezza R, Stolbach BC, Green BL. Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress. 2011 Dec;24(6):615-27. doi: 10.1002/jts.20697. Epub 2011 Dec 6.
• Craig TK, Hodson S. Homeless youth in London: I. Childhood antecedents and psychiatric disorder. Psychol Med. 1998 Nov;28(6):1379-88. doi: 10.1017/s0033291798007351.
• Frederick, T., Chwalek, M., Hughes, J., Karabanow, J., & Kidd, S.A. (2014). How stable is stable? Defining and measuring housing stability. Journal of Community Psychology, 42, 964-979*.
• Gaetz, S., Donaldson, J., Richter, T., & Gulliver, T. (2013). The State of Homelessness in Canada - 2013. Toronto: Canadian Homeless Research Network Press.
• Grabbe, L., Nguy, S. & Higgins, M. (2012). Spirituality development for homeless youth: A mindfulness meditation feasibility pilot. Journal of Child and Family Studies 21, 925-37.
• Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005 Nov;15(9):1277-88. doi: 10.1177/1049732305276687.
• Hurn J, Kneebone I, Cropley M. Goal setting as an outcome measure: A systematic review. Clin Rehabil. 2006 Sep;20(9):756-72. doi: 10.1177/0269215506070793.
• Hwang SW, Kirst MJ, Chiu S, Tolomiczenko G, Kiss A, Cowan L, Levinson W. Multidimensional social support and the health of homeless individuals. J Urban Health. 2009 Sep;86(5):791-803. doi: 10.1007/s11524-009-9388-x. Epub 2009 Jul 23.
• Karabanow J. (2004). Being Young and Homeless: Understanding how youth enter and exit street life. New York, NY. Peter Lang Publishing INC.
• Karabanow, J., Hopkins, S., Kisely, S., Parker, J., Hughes, J., Gahagan, J., and Campbell, LA. (2007). Can You Be healthy on the Street?: Exploring the Health Experiences of Halifax Street Youth. The Canadian Journal of Urban Research, 16, 12-32.
• Karabanow, J. (2008). Getting off the Street: Exploring Young People's Street Exits. American Behavioral Scientist, 51, 772-788.
• Kerrigan D, Johnson K, Stewart M, Magyari T, Hutton N, Ellen JM, Sibinga EM. Perceptions, experiences, and shifts in perspective occurring among urban youth participating in a mindfulness-based stress reduction program. Complement Ther Clin Pract. 2011 May;17(2):96-101. doi: 10.1016/j.ctcp.2010.08.003. Epub 2010 Sep 16.
• Kidd SA, Scrimenti K. Evaluating child and youth homelessness. Eval Rev. 2004 Aug;28(4):325-41. doi: 10.1177/0193841X04264820.
• Kidd, S.A. (2006). Factors precipitating suicidality among homeless youth: A quantitative follow-up. Youth & Society, 37, 393-422.
• Kidd, S.A., & Davidson, L. (2007). "You have to adapt because you have no other choice.": The stories of strength and resilience of 208 homeless youth in New York City and Toronto. Journal of Community Psychology, 35, 219-238.
• Kidd S. Invited commentary: seeking a coherent strategy in our response to homeless and street-involved youth: a historical review and suggested future directions. J Youth Adolesc. 2012 May;41(5):533-43. doi: 10.1007/s10964-012-9743-1.
• Kidd, S.A., Frederick, T., Karabanow, J.,Hughes, J., & Barbic, S. (2016). A mixed methods of recently homeless youth efforts to sustain housing and stability. Child and Adolescent Social Work Journal, 33, 207-218.
• Linehan, M. (2014). DBT Skills Training Manual Second Edition. New York: The Guilford Press.
• Milburn NG, Rice E, Rotheram-Borus MJ, Mallett S, Rosenthal D, Batterham P, May SJ, Witkin A, Duan N. Adolescents Exiting Homelessness Over Two Years: The Risk Amplification and Abatement Model. J Res Adolesc. 2009 Dec 1;19(4):762-785. doi: 10.1111/j.1532-7795.2009.00610.x.
• Public Health Agency of Canada. (2006). Street Youth in Canada. www.publichealth.gc.ca/sti
• Rew L, Horner SD. Personal strengths of homeless adolescents living in a high-risk environment. ANS Adv Nurs Sci. 2003 Apr-Jun;26(2):90-101. doi: 10.1097/00012272-200304000-00002.
• Rosenthal D, Rotheram-Borus MJ, Batterham P, Mallett S, Rice E, Milburn NG. Housing stability over two years and HIV risk among newly homeless youth. AIDS Behav. 2007 Nov;11(6):831-41. doi: 10.1007/s10461-007-9235-6. Epub 2007 May 12.
• Roy E, Haley N, Leclerc P, Sochanski B, Boudreau JF, Boivin JF. Mortality in a cohort of street youth in Montreal. JAMA. 2004 Aug 4;292(5):569-74. doi: 10.1001/jama.292.5.569.
• Roy E, Haley N, Boudreau JF, Leclerc P, Boivin JF. The challenge of understanding mortality changes among street youth. J Urban Health. 2010 Jan;87(1):95-101. doi: 10.1007/s11524-009-9397-9. Epub 2009 Dec 29.
• Roy E, Robert M, Fournier L, Vaillancourt E, Vandermeerschen J, Boivin JF. Residential trajectories of street youth-the Montreal Cohort Study. J Urban Health. 2014 Oct;91(5):1019-31. doi: 10.1007/s11524-013-9860-5.
• Rush B, Castel S, Brands B, Toneatto T, Veldhuizen S. Validation and comparison of diagnostic accuracy of four screening tools for mental disorders in people seeking treatment for substance use disorders. J Subst Abuse Treat. 2013 Apr;44(4):375-83. doi: 10.1016/j.jsat.2012.08.221. Epub 2012 Oct 23.
• Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995 Apr;18(2):179-83. doi: 10.1002/nur.4770180211.
• Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705-14. doi: 10.1016/0277-9536(91)90150-b.
• Slesnick N, Kang MJ, Bonomi AE, Prestopnik JL. Six- and twelve-month outcomes among homeless youth accessing therapy and case management services through an urban drop-in center. Health Serv Res. 2008 Feb;43(1 Pt 1):211-29. doi: 10.1111/j.1475-6773.2007.00755.x.
• Slesnick N, Bartle-Haring S, Dashora P, Kang MJ, Aukward E. Predictors of Homelessness Among Street Living Youth. J Youth Adolesc. 2008;37(4):465-474. doi: 10.1007/s10964-007-9188-0.
• Slesnick N, Dashora P, Letcher A, Erdem G, Serovich J. A Review of Services and Interventions for Runaway and Homeless Youth: Moving Forward. Child Youth Serv Rev. 2009 Jul;31(7):732-742. doi: 10.1016/j.childyouth.2009.01.006.
• Snyder CR, Harris C, Anderson JR, Holleran SA, Irving LM, Sigmon ST, Yoshinobu L, Gibb J, Langelle C, Harney P. The will and the ways: development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991 Apr;60(4):570-85. doi: 10.1037//0022-3514.60.4.570.
• Stergiopoulos V, Gozdzik A, O'Campo P, Holtby AR, Jeyaratnam J, Tsemberis S. Housing First: exploring participants' early support needs. BMC Health Serv Res. 2014 Apr 13;14:167. doi: 10.1186/1472-6963-14-167.
• Tevendale HD, Comulada WS, Lightfoot MA. Finding shelter: two-year housing trajectories among homeless youth. J Adolesc Health. 2011 Dec;49(6):615-20. doi: 10.1016/j.jadohealth.2011.04.021.
• Unesco. (2014, July 4). Street Children. Retrieved from: http://www.unesco.org/new/en/social-and-human-sciences/themes/fight-against-discrimination/education-of-children-in-need/street-children/.
• Wagnild G.M. The Resilience Scale user's guide for the US English version of the Resilience Scale and the 14- Item Resilience Scale (RS-14). Worden, MT: The Resilience Center. 2010.
• Yalom, I.D. & Leszcz, M. (2005). The Theory & Practice of Group Psychotherapy, 5th ed. N.Y.: Basic Books.
• Kidd SA, Vitopoulos N, Frederick T, Leon S, Wang W, Mushquash C, McKenzie K. Trialing the feasibility of a critical time intervention for youth transitioning out of homelessness. Am J Orthopsychiatry. 2020;90(5):535-545. doi: 10.1037/ort0000454. Epub 2020 Apr 20.

Helpful Links

• Information about research at the Centre for Addiction and Mental Health, Canada's largest mental health and addictions teaching hospital.

Study record dates

Study Major Dates

• Study Start (ACTUAL): April 1, 2017
• Primary Completion (ACTUAL): December 31, 2018
• Study Completion (ACTUAL): December 31, 2018

Study Registration Dates

• First Submitted: August 14, 2017
• First Submitted That Met QC Criteria: September 8, 2017
• First Posted (ACTUAL): September 11, 2017

Study Record Updates

• Last Update Posted (ACTUAL): March 18, 2021
• Last Update Submitted That Met QC Criteria: February 24, 2021
• Last Verified: February 1, 2021

More Information

Terms related to this study

• Other Study ID Numbers: 02/06/2017

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No