Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness.

BACKGROUND: This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group. METHODS: Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months. RESULTS: Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income. DISCUSSION: This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).

Behavioral Crisis and First Response: Qualitative Interviews with Chicago Stakeholders.

Improving interactions between first responders and individuals experiencing behavioral crisis is a critical public health challenge. To gain insight into these interactions, key informant qualitative interviews were conducted with 25 Chicago stakeholders. Stakeholders included directors and staff of community organizations and shelters that frequently engage first responders. Interviews included granular depictions related to the expectations and outcomes of 911 behavioral crisis calls, and noted areas requiring improved response. Stakeholders called 911 an average of 2 to 3 times per month, most often for assistance related to involuntary hospitalization. Engagements with first responders included unnecessary escalation or coercive tactics, or conversely, refusal of service. While stakeholders lauded the value of police trained through the city's Crisis Intervention Team program, they emphasized the need for additional response strategies that reduce the role of armed police, and underscored the need for broader social and behavioral health services for individuals at-risk of such crises.

From the streets to a hotel: a qualitative study of the experiences of homeless persons in the pandemic era.

In the wake of COVID-19, programs for housing homeless individuals in hotels have emerged in the U.S., though research has yielded little information about the impact of these programs on participants expressed in their own words. In this qualitative study conducted in a major northeastern city, 13 previously street homeless individuals recount their experiences of hotel housing during the pandemic. Participants were recruited from an advocacy-initiated collaborative that operated with a housing first approach, providing private rooms without requirements or intrusive oversight typically found in shelter environments. Benefits of hotel housing reported include improvements in physical health, sleep, personal hygiene, privacy, safety, nutrition, and overall well-being. Inductive coding by consensus and thematic development yielded three themes. Participants described hotel living as (1) a platform for stability; (2) protection from COVID and other hazards; and (3) freeing mental space for future planning. As research shows hotel programs' success, an unprecedented opportunity has arisen from the pandemic to end homelessness for many. Given current federal budget increases, it is recommended that hotels become part of a larger effort to reduce shelter populations and increase access to independent housing.

Social relationships, homelessness, and substance use among emergency department patients.

Background: Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. Methods: As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. Results: Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. Conclusions: The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.

"Home Is Where Your Root Is": Place Making, Belonging, and Community Building among Somalis in Chicago.

This qualitative study examines the notion of home as it relates to place making, belonging, and community building. Using a phenomenological method of inquiry, data were gathered through in-depth qualitative interviews with 15 Somali Americans and subjected to transcendental phenomenological analyses. Three major themes were found: (1) the meaning of community: being Somali and Muslim; (2) "We help each other. We are connected"; and (3) "Home is where your root is." The study findings highlight how Somali participants drew on their faith and culture as foundational to community building and drew on acts of mutual giving and receiving to bind them together even as subjective feelings of "home" could be place based or could transcend geography. Although sometimes disrupted by bias and discrimination, Somalis persevered in defining themselves and pursuing a sense of belonging both within their own community and in the city at large. This study offers an expansive and dynamic view of the meaning of place making, community building, and belonging (home) in the lives of displaced refugees. Both research and practice can benefit from special attention given to the "natural" formation of refugee communities and their role in enhancing adjustment to life in a new land.

Strategies for Sustaining Fidelity: A Multi-state Qualitative Analysis in Housing First Programs.

Little is known about long-term fidelity of evidence-based interventions (EBIs) under changing conditions. This study examines how staff at 'mature' (eight or more years in operation) Housing First (HF) programs strategize to sustain EBI fit in different geographic areas in the Mid-Atlantic/Northeastern United States. Six focus groups (FGs) at three purposively selected HF programs were conducted with separate FGs for case managers and supervisors at each site. FG discussions elicited participants' service approaches and strategies in addressing fidelity amidst ongoing changes affecting each program. Thematic content analysis of FG transcripts was conducted using the five HF fidelity domains (housing choice/structure, separation of housing and services, service philosophy, service array, and program structure) as a priori themes with inductive content analyses conducted on data in each theme. Strategies for rigor were employed. Case managers (N = 17) and supervisors (N = 16) were predominantly white (76%) and female (60%). Across the themes, challenges included lack of affordable housing and choice, funders' restrictions and practice 'drift.' Strategies included community engagement and hiring, strong leadership and 'bending the rules.' There were no differences across sites. Later-stage implementation challenges show the need for continued vigilance in fidelity to EBIs. Among the strategies used to address fidelity in this study, the pursuit of pro-active community engagement to attract knowledgeable staff as well as increase local buy-in was considered pivotal at all three sites. These findings underscore the need to attend to the external setting as well as to internal program operations.

Homelessness, housing instability and mental health: making the connections.

Research on the bi-directional relationship between mental health and homelessness is reviewed and extended to consider a broader global perspective, highlighting structural factors that contribute to housing instability and its mental ill health sequelae. Local, national and international initiatives to address housing and mental health include Housing First in Western countries and promising local programmes in India and Africa. Ways that psychiatrists and physicians can be agents of changes range from brief screening for housing stability to structural competence training. Narrow medico-scientific framing of these issues risks losing sight of the foundational importance of housing to mental health and well-being.

Eliciting Life Priorities of Older Adults Living in Permanent Supportive Housing.

BACKGROUND AND OBJECTIVES: Adults who have experienced chronic homelessness are considered to be "old" by age 50 due to accelerated aging. While permanent supportive housing (PSH) has been found effective for these individuals, there is limited focus on the needs of adults "aging in place" in PSH. This study examined (1) how older adults in PSH identify and rank their life priorities, (2) how they describe these priorities in their own words, and (3) how life course adversity deepens an understanding of these priorities. RESEARCH DESIGN AND METHODS: A convergent parallel mixed methods design was used in which qualitative case study analyses informed by a life course perspective provided a deeper understanding of how 14 older residents of PSH viewed their life priorities using quantitative card-sort rankings of 12 life domains. RESULTS: Housing, family, mental health, physical health, and partner were the most frequently endorsed life priorities. Four themes emerged from the cross-case analyses: "aging in, aging out," "carefully restoring relationships," "life goes on," and "housing is fundamental." Convergent findings indicated that life adversity-social losses and interrupted lives-influenced both the high- and low-ranked card-sort priorities. DISCUSSION AND IMPLICATIONS: This study demonstrated that participants were aware of their advancing years yet they sought to overcome adversity and losses through maintaining mental health and sobriety, improving physical health, and cautiously rebuilding relationships. As the numbers of older homeless rise, the inclusion of age-related services will be an important component of PSH services for residents as they age.

Employment experiences of formerly homeless adults with serious mental illness in Housing First versus treatment first supportive housing programs.

OBJECTIVE: This paper examines how formerly homeless adults with serious mental illness living in Housing First (HF) and "treatment first" (TF) supportive housing programs experience employment. Research questions include: How do these individuals experience employment in the context of their mental health recovery? What do they perceive as the benefits of and obstacles to attaining employment? Are there programmatic differences in their employment experiences? METHOD: Case study analyses of data from a federally funded qualitative study were conducted of 40 individuals purposively sampled from HF and TF programs. Data were independently analyzed and consensually discussed to develop cross-case themes. RESULTS: Three themes emerged: (a) the meaning of work, (b) working within the system, and (c) balancing treatment requirements and work. While none of the study participants had full-time jobs, more HF program clients had part-time employment than their TF counterparts. Of the 12 employed participants, all but 2 worked within their respective programs. Participants in both groups described similar benefits of obtaining employment, but TF program requirements inhibited job-seeking. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings provide insight into the challenges of obtaining employment for formerly homeless individuals with serious mental illness residing in supportive housing. Despite the motivation to work, individual, structural, and organizational factors impeded employment. To address this problem, factors at each of these levels will need to be considered. Interventions such as supported employment offer promise to supportive housing programs committed to employment as a contributor to recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

How Practice Facilitation Strategies Differ by Practice Context.

BACKGROUND: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

"It Wasn't Just One Thing": A Qualitative Study of Newly Homeless Emergency Department Patients.

OBJECTIVES: Emergency departments (EDs) frequently care for patients who are homeless or unstably housed. One promising approach taken by the homeless services system is to provide interventions that attempt to prevent homelessness before it occurs. Experts have suggested that health care settings may be ideal locations to identify and intervene with patients at risk for homelessness, yet little is known even about the basic characteristics of patients who might benefit from such interventions. METHODS: We conducted in-depth, one-on-one qualitative interviews with ED patients who had become homeless within the past 6 months. Using a semistructured interview guide, we asked patients about their pathways into homelessness and what might have prevented them from becoming homeless. Interviews were digitally recorded and professionally transcribed. Transcripts were coded line by line by multiple investigators who then met as a group to discuss and refine codes in an iterative fashion. RESULTS: Interviews were completed with 31 patients. Mean interview length was 42 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected. CONCLUSIONS: These findings demonstrate gaps in current homeless prevention services and can help inform future interventions for unstably housed and homeless ED patients. More immediately, the findings provide rich, unique context to the lives of a vulnerable patient population commonly seen in EDs.

"If you're gonna help me, help me": Barriers to housing among unsheltered homeless adults.

Despite a legally-mandated right to shelter and extensive outreach efforts, an estimated 3,675 homeless individuals were living on the streets of New York City in 2018. Through interviews with 43 unsheltered homeless individuals in the borough of Manhattan (age range 21-74 years), this qualitative study examined barriers they face in accessing housing and other services as well as experiences surviving on the street. Through thematic analysis of the interview data, the most common barriers found were obtaining required identification documents, lack of accessibility of shelters amid complex healthcare needs, waiting as part of the process, and exclusion of pets from shelters and housing options. Themes capturing survival on the street included sleeping safe, avoiding shelters, and meeting daily needs. Virtually all barriers street homeless New Yorkers face stem from bureaucratic policies that, however well-intentioned, do not address their diverse needs. Thus, long delays and poor communication, combined with crowded, unsafe shelters, lead to frustration and alienation. While homelessness is ultimately the result of a severe and chronic shortage of affordable housing, creating accessible, safe, pet-friendly shelter and safe haven options and instituting a smoother, more transparent process for moving from the streets could substantially reduce street homelessness.

Trajectories of Recovery Among Formerly Homeless Adults With Serious Mental Illness.

OBJECTIVE: Recovery from mental illness is possible, but individuals with co-occurring disorders and homelessness face challenges. Although a nonlinear recovery course is assumed, few studies have analyzed recovery over time. This mixed-methods study examined recovery trajectories over 18 months after enrollment in supportive housing programs of 38 participants with DSM axis I diagnoses. METHODS: Qualitative interview data were quantified through consensual ratings to generate a recovery score for four waves of data collection based on eight recovery domains culled from the literature. Case study analyses were conducted of participants whose scores varied by one standard deviation or more between baseline and 18 months to identify which domains were important. RESULTS: Most of the 38 participants (N=23) had no significant change in recovery; seven had a negative trajectory, and eight had a positive trajectory. Case studies of these 15 participants indicated domains that contributed to change: significant-other relationships (N=9), engagement in meaningful activities (N=9), mental health (N=7), family relationships (N=6), general medical health (N=5), housing satisfaction (N=5), employment (N=2), and substance use (N=1). Except for mental health and substance use (which contributed only to negative trajectories), the influence of domains was both positive and negative. Domains were intertwined; for example, variation in relationships was linked to changes in meaningful activities. CONCLUSIONS: This study showed little change in recovery over time for most participants and a decline in mental health for a small minority. Findings underscore the importance of social relationships and meaningful activities among individuals with serious mental illness, who experience complex challenges.

Case Manager Perspectives on the Role of Treatment in Supportive Housing for People with Severe Mental Illness.

OBJECTIVE: Growing recognition exists of housing as a social determinant of health, and thus, health care reform initiatives are expanding the reach of health care beyond traditional settings. One result of this expansion is increased Medicaid funds for supportive-housing programs for people with severe mental illnesses. This qualitative study explores the ways in which case managers working in a supportive housing program approach treatment and how their approach is influenced by both program requirements and their beliefs about mental illness. METHOD: The study is part of a longitudinal qualitative study on recovery for people with severe mental illnesses living in supportive housing. Multiple interviews (n = 55) with 24 case managers from a residential-continuum supportive-housing program were conducted over 18 months. To provide an in-depth view of case manager perspectives, the study uses thematic analysis with multiple coders. RESULTS: Overall, case managers understand supportive housing as being a treatment program but predominantly characterize treatment as medication management. The following themes emerged: believing medication to be the key to success in the program, persuading residents to take medication, and questioning the utility of the program for residents who were not medication adherent. CONCLUSIONS: Case managers understand supportive housing to be a treatment program; however, given the external constraints and their own beliefs about mental illness, case managers often equate treatment with taking medication. Study findings demonstrate the need to train case managers about mental health recovery and integrated health care. The findings also have implications for policies that tie housing to services.

Unpacking Clinical Supervision in Transitional and Permanent Supportive Housing: Scrutiny or Support?

Behavioral health organizations use clinical supervision to ensure professional development and practice quality. This qualitative study examined 35 service coordinators' perspectives on supervision in two distinct supportive housing program types (permanent and transitional). Thematic analysis of in-depth interviews yielded three contrast themes: support versus scrutiny, planned versus impromptu time, and housing first versus treatment first. Supervisory content and format resulted in differential perceptions of supervision, thereby influencing opportunities for learning. These findings suggest that unpacking discrete elements of supervision enactment in usual care settings can inform implementation of recovery-oriented practice.

Complex Recovery: Understanding the Lives of Formerly Homeless Adults with Complex Needs.

OBJECTIVE: This report examines mental health recovery in a population neglected in the literature--formerly homeless adults with serious mental illness and co-occurring substance abuse. The term 'complex recovery' is used to examine the onset and impact of various types of adversity over the life course. METHOD: Burawoy's extended case method was conducted on in-depth interviews with 74 formerly homeless adults living in housing programs in New York City. Data included verbatim transcripts, interviewer feedback forms, and case summaries. RESULTS: Seven themes emerged: the longstanding influence of poverty, childhood hardship, social support and network depletion, substance abuse and recovery, unequal impact of gender differences, experiences of incarceration and fragmented service system. Structural as well as individual factors were found to comprise complex recovery. CONCLUSIONS: Complex recovery, which situates mental health recovery amidst homelessness and other forms of adversity, has implications for policies and practices designed to assist this vulnerable population.

Social Relationships of Dually Diagnosed Homeless Adults Following Enrollment in Housing First or Traditional Treatment Services.

OBJECTIVE: Strong and effective social support is a critical element of mental health recovery, yet social support is often lacking for adults experiencing homelessness. This study examines differences in the social networks of participants newly enrolled in programs that use either a Housing First (HF) approach (i.e., provides immediate access to permanent housing with ongoing consumer-driven support services) or a treatment first (TF) approach (i.e., traditional clinician-driven staircse model that requires temporary or transitional housing and treatment placements before accessing permanent housing). METHOD: We use a mixed-methods social network analysis approach to assess group differences of 75 individuals based on program type (HF or TF) and program retention. RESULTS: Quantitative results show that compared with TF, HF participants have a greater proportion of staff members in their network. TF participants are more likely than HF participants to maintain mixed-quality relationships (i.e., relationships with elements of support and conflict). As compared with participants who remain in a program, those who disengage from programs have a greater proportion of mixed relationships and relationships that grow distant. Qualitative analyses suggest that HF participants regard housing as providing a stable foundation from which to reconnect or restore broken relationships. However, HF participants are guarded about close relationships for fear of being exploited due to their newly acquired apartments. TF participants report that they are less inclined to develop new relationships with peers or staff members due to the time-limited nature of the TF programs. CONCLUSIONS: These findings suggest that HF participants are not more socially isolated than those in traditional care. Implications for practice, policy and future research are discussed.

Rebuilding lives and identities: The role of place in recovery among persons with complex needs.

Photo-elicitation interviews (PEIs) were conducted to explore the role of place in recovery - specifically, narrative identity reconstruction - among persons with complex needs. PEIs with 17 formerly homeless adults with co-occurring disorders in New York City produced 243 photos. Content analysis of photos revealed three categories - apartment, neighborhood and people. Two narrative themes - having my own and civic identity - were mapped onto the apartment and neighborhood categories, respectively. Three additional cross-categorical narrative themes were identified: (re)negotiating relationships and boundaries, moving beyond old identities and future possibilities. Housing was central across themes. Understanding of recovery is enhanced when viewed through participant-controlled visual methods.