Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE (Open Access)

Evaluation of an integrated housing and recovery model for people with severe and persistent mental illnesses: the Doorway program*

David R. Dunt A H , Andrew W. Benoy B , Andrea Phillipou C , Laura L. Collister D , Elizabeth M. Crowther D , Julian Freidin E and David J. Castle F G
+ Author Affiliations
- Author Affiliations

A Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Vic. 3010, Australia.

B Nous Group, Level 10, 485 Bourke Street, Melbourne, Vic. 3000, Australia. Email: Andrew.Benoy@nousgroup.com.au

C Department of Mental Health, St Vincent’s Hospital, Level 2, 46 Nicholson Street, Fitzroy, Vic. 3065, Australia. Email: Andrea.phillipou@svha.org.au

D MI Fellowship Wellways, Fairfield Place, 276 Heidelberg Road, Fairfield, Vic. 3078, Australia. Email: lcollister@mifellowship.org; ecrowther@mifellowship.org

E Homeless Outreach Psychiatric Service, Department of Psychiatry, Alfred Hospital, PO Box 315, Prahran, Vic. 3181, Australia. Email: Julian.freidin@gmail.com

F St. Vincent’s Hospital, Melbourne, Nicholson Street, Fitzroy, Vic. 3065, Australia. Email: David.castle@svha.org.au

G The University of Melbourne, PO Box 2900, Fitzroy, Vic. 3065, Australia.

H Corresponding author. Email: d.dunt@unimelb.edu.au

Australian Health Review - https://doi.org/10.1071/AH16055
Submitted: 26 February 2016  Accepted: 23 August 2016   Published online: 21 October 2016

Abstract

Objective The Doorway program is a 3-year pilot integrated housing and recovery support program aimed at people with a severe and persistent mental illness who are ‘at risk’ or actually homeless. Participants source and choose properties through the open rental market, with appropriate rental subsidy and brokerage support. This arrangement is highly innovative, differing from widely favoured arrangements internationally involving congregate and scattered-site housing owned or managed by the support program. The aim of the present study was to determine the effects of the Doorway program on participants’ health, housing, service utilisation and costs.

Methods A pre-post study design was used with outcome measures consisting of a number of question inventories and their costs (where relevant). The principal inventories were the Behaviour and Symptom Identification Scale 32 (BASIS-32), a consumer-oriented, self-report measure of behavioural symptoms and distress, the Health of the Nation Outcome Scale (HoNOS), an interviewer-administered measurement tool designed to assess general health and social functioning of mentally ill people and the Outcomes Star (Homelessness) system which measures various aspects of the homelessness experience. Baseline measurements were performed routinely by staff at entry to the program and then at 6-monthly intervals across the evaluation period.

Results For 55 of 59 participants, total mean BASIS-32 scores (including as well three of five subscale scores) improved significantly and with moderate effect size. Four of the 10 domain scores on the Outcome Star (Homelessness) inventory also improved significantly, with effect sizes ranging from small–medium (three domains) to large (one domain). Mean usage of bed-based mental health clinical services and general hospital admissions both significantly decreased (with overall net savings of A$3096 per participant per annum). Overall cost savings (including housing) to government ranged from A$1149 to A$19 837 depending on the housing type comparator.

Conclusion The Doorway program secured housing for this vulnerable group with additional benefits in client outcomes, including reduced use and cost of health services. These findings, if confirmed in larger studies, should have widespread applicability internationally.

What is known about the topic? Beneficial effects of housing and recovery programs (Housing First) on people with severe and persistent mental illness and who are ‘at risk’, or actually homeless, are being demonstrated in Northern America. These effects include housing security, well being, health service utilisation and cost effects on government. However, these beneficial effects can only be regarded as settled for housing security. The highly innovative Doorway care model in which participants source and choose properties through the open rental market, with appropriate rental subsidy and brokerage support, has not been investigated previously.

What does this paper add? This paper adds new data on the Doorway care models, it’s effects and costs, particularly with regard to participant behavioural distress and social functioning.

What are the implications for practitioners? The beneficial effects of this innovative model, if confirmed in larger studies, should have widespread applicability internationally.

Additional keywords: health funding and financing, health services research, mental health, models of care.


References

[1]  Nous Group. Doorway – Summative Evaluation – November 2013. Melbourne: Nous Group; 2014. Available at: http://www.mifellowship.org/sites/default/files/Doorway%20-%20Summative%20Evaluation%20Report%20-%20FINAL%20-%20140205.pdf [verified 12 September 2016].

[2]  Morgan V, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, Bush R, Castle D, Cohen M, Harvey C, Galletly C, Stain HJ, Neil AL, McGorry P, Hocking B, Shah S, Saw S. People living with psychotic illness in 2010: the second Australian national survey of psychosis. Aust N Z J Psychiatry 2012; 46 735–52.
People living with psychotic illness in 2010: the second Australian national survey of psychosis.CrossRef | 22696547PubMed | open url image1

[3]  Morgan VA, McGrath JJ, Jablensky A, Badcock JC, Waterreus A, Bush R, Carr V, Castle D, Cohen M, Galletly C, Harvey C, Hocking B, McGorry P, Neil AL, Saw S, Shah S, Stain HJ, Mackinnon A. Psychosis prevalence and physical, metabolic and cognitive comorbidity. Data from the second Australian national survey of psychosis. Psychol Med 2014; 44 2163–76.
Psychosis prevalence and physical, metabolic and cognitive comorbidity. Data from the second Australian national survey of psychosis.CrossRef | 1:STN:280:DC%2BC2c3ps1CjsA%3D%3D&md5=656cf923e4eac8e72af72f34404ee696CAS | 24365456PubMed | open url image1

[4]  Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatry 2014; 59 236–42.
| 25007276PubMed | open url image1

[5]  Chamberlain C, MacKenzie D. Counting the Homeless 2001. Catalogue No. 2050.0. Canberra: Australian Bureau of Statistics; 2003.

[6]  Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health 2004; 94 651–6.
Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis.CrossRef | 15054020PubMed | open url image1

[7]  Patterson M, Moniruzzaman A, Palepu A, Zabkiewicz D, Frankish CJ, Krausz M, Somers JM. Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia. Soc Psychiatry Psychiatr Epidemiol 2013; 48 1245–59.
Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia.CrossRef | 23748928PubMed | open url image1

[8]  Somers J, Rezansoff SN, Moniruzzaman A, Palepu A, Patterson M. Housing First reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial. PLoS 2013; 8 e72946
Housing First reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial.CrossRef | 1:CAS:528:DC%2BC3sXhsVCrsrbK&md5=ac75e95127476dd793b00476ed4c0afcCAS | open url image1

[9]  Kirst M, Zerger S, Misir V, Hwang S, Stergiopoulos V. The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness. Drug Alcohol Depend 2015; 146 24–9.
The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness.CrossRef | 25465295PubMed | open url image1

[10]  Somers JM, Moniruzzaman A, Palepu A. Changes in daily substance use among people experiencing homelessness and mental illness: 24-month outcomes following randomization to Housing First or usual care. Addiction 2015; 110 1605–14.
Changes in daily substance use among people experiencing homelessness and mental illness: 24-month outcomes following randomization to Housing First or usual care.CrossRef | 26052657PubMed | open url image1

[11]  Stergiopoulos V, Hwang SW, Gozdzik A, Nisenbaum R, Latimer E, Rabouin D, Adair CE, Bourque J, Connelly J, Frankish J, Katz LY, Mason K, Misir V, O’Brien K, Sareen J, Schütz CG, Singer A, Streiner DL, Vasiliadis HM, Goering PN, At Home/Chez Soi Investigators 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 2015; 313 905–15.
Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial.CrossRef | 1:CAS:528:DC%2BC2MXkvFKnt70%3D&md5=a71e8c8b91f6ee6c742b7fe6349887e0CAS | 25734732PubMed | open url image1

[12]  Bruce J, McDermott S, Ramia I, Bullen J, Fisher KR. Evaluation of the Housing and Accommodation Support Initiative (HASI) Final Report, for NSW Health and Housing NSW. Sydney: Social Policy Research Centre, UNSW; 2012. Available at: http://www.health.nsw.gov.au/mentalhealth/publications/Publications/pub-hasi-final-report.pdf [verified 12 September 2016].

[13]  Johnson G, Kuehnle D, Parkinson S, Sesa S, Tseng Y-P. Sustaining exits from long-term homelessness: a randomised controlled trial examining the 48 month social outcomes from the Journey to Social Inclusion pilot program. Melbourne: Sacred Heart Mission; 2014. Available at: https://www.sacredheartmission.org/sites/default/files/publication-documents/j2si_sustaining_exits_from_longterm_homelessness_2015.pdf [verified 12 September 2016].

[14]  Meehan T, Stedman T, Robertson S, Drake S, King R. Does supported accommodation improve the clinical and social outcomes for people with severe psychiatric disability? The Project 300 experience. Aust N Z J Psychiatry 2011; 45 586–92.
Does supported accommodation improve the clinical and social outcomes for people with severe psychiatric disability? The Project 300 experience.CrossRef | 21534823PubMed | open url image1

[15]  Eisen SV, Dill DL, Grob MC. Reliability and validity of a brief patient-report instrument for psychiatric outcome evaluation. Psychiatr Serv 1994; 45 242–7.
Reliability and validity of a brief patient-report instrument for psychiatric outcome evaluation.CrossRef | 1:STN:280:DyaK2c3ksFWhtA%3D%3D&md5=70445e394a85cd8bbe7090b36e74971fCAS | open url image1

[16]  Eisen SV, Grob MC, Klein AA. BASIS: the development of a self-report measure for psychiatric inpatient evaluation. Psychiatr Hosp 1986; 17 165–71.
| 1:STN:280:DyaL2s3jt12iug%3D%3D&md5=77c7b8ea1d201b385d69fabb9a52b40aCAS | 10282438PubMed | open url image1

[17]  Wing JK, Beevor AS, Curtis RH, Park SB, Hadden S, Burns A. Health of the Nation Outcome Scales (HoNOS). Br J Psychiatry 1998; 172 11–8.
Health of the Nation Outcome Scales (HoNOS).CrossRef | 1:STN:280:DyaK1c7ps1ehtg%3D%3D&md5=f925fa53a6683e4df86fd98f4589e39dCAS | 9534825PubMed | open url image1

[18]  Victorian Government Department of Health. Client Management Interface/Operational Data Store service contacts. 2015. Available at: https://www2.health.vic.gov.au/mental-health/research-and-reporting/reporting-requirements-for-clinical%20mental-health-services/service-contacts [verified 3 November 2015].

[19]  Victorian Government Department of Health. Victorian health services policy and funding guidelines 2010–11: highlights. Melbourne: Department of Health; 2010.

[20]  Independent Hospital Pricing Authority. National Hospital Cost Data Collection Australian Public hospitals cost report 2010–2011, round 15. Canberra: Commonwealth of Australia; 2013.

[21]  Australian Institute of Health and Welfare (AIHW). Australian hospital statistics 2010–11. Health Services Series no. 43. Catalogue no. HSE 117. Canberra: AIHW; 2012.

[22]  Mental Illness Fellowship. Proposal for housing pilot project – July 2009. Melbourne: Mental Illness Fellowship; 2009.

[23]  Victorian Government Department of Health. Housing support and brokerage demonstration project. Melbourne: Victorian Department of Health; 2011.

[24]  Steering Committee for the Review of Government Service Provision. Attachment Tables GA.19 (Indigenous CRA recipients, by payment type, 2012 (a), (b), (c)) and GA.22 (Median CRA entitlement, by location, 2012 (a), (b), (c)). In: Chapter 16 Housing and homelessness Sector overview Canberra: Productivity Commission; 2013. Available at: http://www.pc.gov.au/research/ongoing/report-on-government-services/2016/community-services/youth-justice/rogs-2016-volumef-chapter16.pdf [verified 12 September 2016].

[25]  Zaretzky KP, Flatau P. The cost of homelessness and the net benefit of homelessness programs: a national study. Melbourne: Australian Housing and Urban Research Institute (AHURI); 2013.

[26]  Sadowski L, Kee R, VanderWeele T, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA 2009; 301 1771–8.
Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial.CrossRef | 1:CAS:528:DC%2BD1MXls1Wjt78%3D&md5=a8007defd411cc3e96d2edc2df2f129eCAS | 19417194PubMed | open url image1

[27]  Rosenheck R, Kasprow W, Frisman L, Liu-Mares W. Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry 2003; 60 940–51.
Cost-effectiveness of supported housing for homeless persons with mental illness.CrossRef | 12963676PubMed | open url image1

[28]  Gilmer TP, Stefancic A, Ettner SL, Manning WG, Tsemberis S. Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness. Arch Gen Psychiatry 2010; 67 645–52.
Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness.CrossRef | 20530014PubMed | open url image1

[29]  Gilmer TP, Stefancic A, Tsemberis S, Ettner SL. Full-service partnerships among adults with serious mental illness in California: impact on utilization and costs. Psychiatr Serv 2014; 65 1120–5.
Full-service partnerships among adults with serious mental illness in California: impact on utilization and costs.CrossRef | 24829104PubMed | open url image1


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