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Community-based service providers working with people experiencing homelessness encounter many occupational challenges and high turnover rates are a challenge in the sector. This qualitative study examined the perceived causes and decision paths of turnover among service providers working with people experiencing homelessness in Canada. In-depth interviews were completed with 40 service providers working in homeless service, supportive housing, and harm reduction programs. Thematic analysis and a deductive-based matrix analysis were used to identify causes and decision paths of turnover, respectively. Primary causes of employee turnover included: (1) career advancement and growth; (2) incongruence between providers' needs, values, and work position; (3) mental health deteriorations; (4) organizational stability and support issues; and (5) staff dismissal. Further, two contextual factors – low sectoral wages and a transitory work culture – shaped service providers' occupational experiences and had indirect effects on turnover. Push and pull decisions were the primary paths to voluntary turnover among participants. Overall, the findings highlight that employee turnover often occurs voluntarily when service providers experience unmet occupational or work-interacting personal needs, or want to pursue new career-related opportunities. Practice and policy recommendations, including use of realistic job previews and establishment of workforce development strategies, are made to prevent turnover. [ABSTRACT FROM AUTHOR]

Homeless services systems are now employing Moving On Initiatives (MOIs) to assist formerly homeless residents of permanent supportive housing programs with the transition from these highly supportive programs to affordable housing without the embedded supports. There remains a dearth of evidence on the effectiveness of these initiatives in regard to post-move housing retention and other participant outcomes, and no review of MOI evaluation outcomes has been conducted to date. To address this gap, a scoping review was used to map and summarize the existing literature on MOI participant outcomes and discuss outstanding gaps in this body of literature. Overall, the early evidence on this emerging approach is promising as this review finds high rates of post-move housing retention and other positive participant outcomes in the few sources located that describe MOI outcomes. However, large-scale studies of MOIs with longer follow-up periods are needed to assess the long-term effectiveness and outcomes of these initiatives. [ABSTRACT FROM AUTHOR]

Permanent supportive housing (PSH) programs are now using Moving On initiatives (MOIs) to increase the homeless service system capacity. These initiatives support tenants with the transition from PSH to mainstream affordable housing by providing them with mainstream housing assistance and various transitional services. Research on this approach has primarily consisted of evaluations of individual programs. Less is known about MOI implementation features across programs. This study utilizes a document review and descriptive survey of 27 MOIs to describe MOI implementation variation and identify common strategies for helping people to move on from PSH. Findings suggest that a wide degree of variation exists in these approaches between and within MOI programs. Two primary types of move on strategies were identified: "Moving Up and Out" and "Transitioning in Place." Implications for the homeless service system are discussed. [ABSTRACT FROM AUTHOR]

This study describes expert perspectives on service user transitions within and from homeless service programs. Semi-structured qualitative interviews were conducted with subject matter experts (SMEs) who had practice or research experience regarding transitional supports in homeless services. Interviews were analyzed using rapid assessment procedures that allowed for the categorization and characterization of targeted interview domains. Findings indicate that assessment is a critical, but underspecified, aspect of transitional programs in homeless services. SMEs viewed assessments for transition readiness as goal-setting opportunities and said that frequency of assessment is best individualized to the person. Transitional supports, including housing navigation and peer support, were viewed as important elements of successful programs. SMEs further noted that opportunities for eventual transition from the program should be communicated to service users early on and that having an organizational culture that embraces service user transitions was critical, highlighting the importance of shifting culture around transitions in homeless services. [ABSTRACT FROM AUTHOR]

To address the ongoing supply-demand gap for permanent supportive housing (PSH), Moving On initiatives (MOIs) provide linkage to affordable housing without embedded support services and rental subsidies, as well as short-term transitional case management to support transitions to independent housing. PSH providers mediate outcomes for individuals moving on from PSH by providing appropriate supports and assistance. Yet, little is known about how providers view these moves. This study explores how providers perceive moves from PSH. Individual interviews were completed with PSH providers from seven U.S. agencies. Data was analyzed via a modified grounded theory approach. The data show that organizational support and prior experience with moving on shape providers’ perceptions of resident capacity. These perceptions were associated with gatekeeping and recovery-oriented approaches, which informed providers’ selfperceived role as following or leading residents towards moving on. Systemlevel support and pressure to adopt a moving on mindset may lead more providers to promote independence and autonomy among individuals with histories of homelessness. [ABSTRACT FROM AUTHOR]

Globally, homelessness has grown over the past decade due to a diverse range of social and economic factors, including lack of affordable housing and retrenchment of social programs. People experiencing homelessness (PEH) experience markedly higher disease burdens than housed populations, as well as reduced access to healthcare. Street Medicine is a promising form of healthcare delivery that seeks to address the healthcare needs of this population despite known structural barriers to access. However, there is limited empirical literature describing Street Medicine practice and program elements. To address this gap, scoping review methods were used to review two major academic databases, web-based literature, and sources provided by content experts. Studies had to specifically reference "Street Medicine" as healthcare delivery and at least one of the review's primary focuses: definitions, philosophies, or program elements. We conducted qualitative analysis to identify relevant themes. Of 1,016 unique sources identified, 349 met inclusion criteria. Six practice categories were identified: direct care, wraparound health services, harm reduction services, psychosocial case management, provision of life necessities, and education/research/advocacy. Despite a shared definition, there are a wide variety of Street Medicine program elements in use. This review sets parameters around which future research on effectiveness of these elements could be based. [ABSTRACT FROM AUTHOR]

This scoping review examines how housing "readiness" is assessed among permanent supportive housing residents before transitioning to mainstream housing through a Moving on initiative (MOI). This paper connects the concept of housing-readiness to concepts of readiness in mental health and substance use treatment, as well as to notions that any concept of readiness implies a category of non-readiness. It then employs scoping review methods to map the existing literature on MOI readiness assessments and markers of readiness, in order to discuss outstanding gaps in this field and inform future MOI practices. Sources were screened according to specified inclusion criteria, resulting in a total of 19 sources. Inclusion required indication of a readiness assessment approach or tool, or some marker of readiness. Common markers described in these sources include financial stability, health and behavioral health, housing stability, support needs, independent living skills, and housing choice. Overall, this review finds common themes across sources that can guide future research on the effectiveness of readiness assessment tools and markers of readiness. Findings can inform future MOIs, participant preparation and engagement in PSH, and the design of readiness assessment tools in the wider field of homelessness services. [ABSTRACT FROM AUTHOR]

Service providers working with people experiencing homelessness can be directly and indirectly exposed to trauma and other chronic stressors in their work. The types of individuals that are most at-risk of problematic outcomes from traumatic event exposure are unknown. This study examined exposure to and effects of workplace traumas and stressors among service providers working with people experiencing homelessness in Canada. A cross-sectional survey was completed by 701 direct service providers working in the homeless service, supportive housing, and harm reduction sectors. Descriptive statistics, hierarchical multiple regression, and double moderation models were used in the analysis. Employment in homeless service settings, service provision to single adults, and more time in direct contact with service users were each positively associated with the frequency of exposure to critical events and chronic stressors. Younger age, lived experience of behavioural health problems, more frequent exposure to chronic stressors, and less social support from coworkers were significantly correlated with post-traumatic stress and general psychological distress. Emotional support from supervision moderated the relationship between direct exposure to workplace critical events and post-traumatic stress. More trauma-informed psychosocial supports tailored to the needs of direct service providers working with people experiencing homelessness are needed. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has had deleterious effects on individuals experiencing homelessness; yet, less is known about how this global health crisis is impacting service providers that support the homeless population. This qualitative study examined the perceived impacts of the COVID‐19 pandemic on the lives and work experiences of service providers in the homeless service, supportive housing, and harm reduction sectors in Canada. Further analyses were conducted to identify the occupational values that were represented in the work‐related changes experienced by providers. A stratified purposive sample of 40 participants (30 direct service providers and 10 providers in leadership roles) were drawn from a pan‐Canadian study of the mental health of service providers working with individuals experiencing homelessness. Reflexive thematic analysis was used to identify five themes of the work‐related changes experienced by service providers during the pandemic: [1] "Everything was changing every day": Work role and responsibility instability; [2] "How on Earth do we do our job?": Challenges to working relationships with service users; [3] "It used to be a social environment": Transitions to impersonal and isolating workspaces; [4] "It all comes down the chute": Lack of organisational support and hierarchical conflict; and [5] "We've been supported as well as we could have": Positive organisational support and communication. The findings underscored how many of the occupational changes during the pandemic did not align with service providers' occupational values for collaboration, control, effective and safe service provision, and the importance of human relationships, among other values. As pre‐existing sectoral problems were exacerbated by the pandemic, recovery efforts need to address these long‐standing issues in ways that are aligned with service providers' values. Future research is warranted on how organisational approaches can promote supportive workplaces for service providers and improve outcomes for individuals experiencing homelessness. [ABSTRACT FROM AUTHOR]

The Quadruple Aim is a health policy framework with the objective of concurrently improving population health, enhancing the service experience, reducing costs and improving the work‐life of service providers. Permanent supportive housing (PSH) is a best practice approach for stably housing people experiencing homelessness who have diverse support needs. Despite the intervention's strong evidence base, little is known about the work‐life of PSH providers. This study explored the mental health and work challenges experienced by PSH providers in Canada. Using an explanatory sequential, equally weighted, mixed methods design, 130 PSH providers were surveyed, followed by semi‐structured interviews with 18 providers. Quantitative findings showed that 23.1% of PSH providers had high psychological distress. Participants who were younger, spent all or almost all of their time in direct contact with service users and had less social support from coworkers were significantly more likely to have high psychological distress. Three themes were identified from the qualitative analysis that showed how PSH providers experience psychological distress from work‐related challenges: (a) Sisyphean Endeavours: 'You Do What You Can', (b) Occupationally Unsupported: 'Everyone Is Stuck in Their Zone' and (c) Wear and Tear of 'Continuous Exposure to Crisis and Chaos'. The themes interacted with systemic (Sisyphean Endeavours) and organisational issues (Occupationally Unsupported), intensifying the emotional burden of day‐to‐day work, which involved frequent crises and uncertainty (Wear and Tear of 'Continuous Exposure to Crisis and Chaos'). The findings underscore how these challenges threaten providers' wellness at work and have implications for the care provided to service users. Accordingly, the Quadruple Aim is a potentially useful and applicable framework for measuring the performance of PSH programs, which warrants further consideration in research and policy. [ABSTRACT FROM AUTHOR]

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Moving On initiatives present opportunities for stable individuals to move from permanent supportive housing (PSH) into mainstream affordable housing. However, there is a dearth of research on how best to support individuals during this critical transition. This mixed-methods study examines transitional and aftercare services needed and received by individuals moving on through an MOI. Descriptive statistics quantified frequency of services needed and received as reported by movers (n = 43) in a post-move survey. Movers (n = 25) also completed pre- and post-move qualitative interviews regarding the transition and thematic analysis was used to elucidate how and why various supports were helpful to movers. During the pre-move transition, housing navigation and help obtaining financial assistance were the most frequently needed services. Movers relied on informal family and peer support to supplement provider assistance in these areas. Case manager visits were the most frequently needed aftercare service and financial assistance was the greatest unmet post-move need. In both periods, formal peer support was an identified service gap. This MOI generally met the self-identified needs of movers. However, MOIs may benefit from better targeting and more robust services specific to housing discrimination, tenants' rights, formal peer support, and financial assistance. [ABSTRACT FROM AUTHOR]

Trauma exposure is highly prevalent in vulnerable groups served by social workers, as well as in populations that are the focus of social work research. Because of this, the field of social work now recognizes the importance of integrating a trauma-informed framework into clinical practice curricula at the bachelors, masters and doctoral levels. Yet this framework is largely absent from instruction on social work research methods and ethics. Through an assessment of contemporary trauma theory, trauma-informed care, and principles of trauma-informed research, the authors argue for 'universal precautions' with social work research populations and adding a trauma-informed lens to existing guidelines for ethical research with human subjects. Organizational strategies for applying a trauma-informed framework within social work research education include: 1) incorporating trauma awareness into research courses; 2) teaching self-care strategies to combat vicarious traumatization; 3) including explicit content on 'two-way' safety in research courses; 4) providing support for research mentors and teams to encourage trauma-informed supervision; and 5) promoting social work research that rebuilds control and empowerment, such as action research and community-based participatory research. [ABSTRACT FROM AUTHOR]

Moving On initiatives (MOIs) transition stable permanent supportive housing (PSH) residents into mainstream housing without embedded services. While this approach frees up PSH for homeless individuals in need, open questions remain regarding MOI recipients' long‐term outcomes. This exploratory study examines how housing environment and residential satisfaction, potential predictors of housing retention, change from PSH to mainstream housing. Subjective assessments of housing and neighborhood quality and residential satisfaction, as well as objective neighborhood‐level data, are used to examine housing‐related change for New York City MOI recipients. Participants generally moved to less‐distressed neighborhoods with lower poverty and crime. Subjective perceptions of some aspects of neighborhood and housing quality also improved post‐move. Participants tended to move farther from public transportation but were on average located within one mile of the nearest subway station. Results can be taken as early indicators of the potential benefits of MOIs. [ABSTRACT FROM AUTHOR]

Aims: This study explored community integration within a Moving On initiative that assisted individuals with the transition from permanent supportive housing (PSH) to more independent housing without service requirements. Methods: Participants completed baseline interviews while in PSH (n = 90) and, for those who moved on, a follow‐up 1‐year post‐move (n = 45). Bivariate analyses and OLS regression were used to examine community integration outcomes and potential correlates. Results: For participants who moved on, subjective social quality of life and sense of community were higher post‐move, while physical integration decreased, and time spent at home increased. Gender, mastery, and housing quality were associated with community integration post‐move. Conclusion: Moving On did not adversely impact most aspects of community integration, though PSH residents may need more support to facilitate participation in routine activities outside their home post‐move. Findings also highlight the importance of supporting mastery given its potential role in community integration. [ABSTRACT FROM AUTHOR]

This multi-method qualitative study examines frontline provider perspectives on consumer social relationships and barriers to social recovery in supportive housing programs for adults with serious mental illness. Thematic analyses show that guest and occupancy policies that enforce the 'single' nature of single-adult supportive housing challenge consumer rights to self-determination in the realm of social recovery. Findings also highlight the ways in which providers act to reinforce and subvert these policies while mitigating risk in this service setting. Recommendations for enhancing the recovery orientation of supportive housing and implications for the design of the homeless service system are discussed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM PUBLISHER]

This study aims to understand participant priorities in their personal recovery journey and their perspectives of recovery domains. A card-sort data-gathering technique was employed to elicit priorities in recovery from consumers in supportive housing programs serving adults who were formerly homeless with severe mental illnesses in New York City. Participants (N = 38) were asked to sort 12 cards printed with recovery domains in order of importance and describe the meaning attached to each domain. Mental health (95%), physical health (89%), and housing (92%) were the domains most frequently included and prioritized in the top three rankings. Family (76%) and partner (74%) were also frequently included and endorsed as most important second only to mental health. Housing was prioritized yet rated most important less often (58%). Work, school, hobbies, program, friends, and neighborhood were less frequently endorsed. “Card-sort talk” revealed critical understanding of participants’ priorities and their reasons for endorsing other domains less frequently. Most important to participants was regaining functional independence through improved mental and physical health and access to housing. With underlying principles of efficiency and empowerment, card sort is a promising engagement technique for providers to elicit consumer priorities in their own recovery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: The harm reduction approach has become a viable framework within the field of addictions, yet there is limited understanding about how this approach is implemented in practice. For people who are homeless and have co-occurring psychiatric and substance use disorders, the Housing First model has shown promising results in employing such an approach. This qualitative study utilizes ethnographic methods to explore case managers'' use of harm reduction within Housing First with a specific focus on the consumer–provider relationship. Analysis of observational data and in-depth interviews with providers and consumers revealed how communication between the two regarding the consumer''s substance use interacted with the consumer–provider relationship. From these findings emerged a heuristic model of harm reduction practice that highlighted the profound influence of relationship quality on the paths of communication regarding substance use. This study provides valuable insight into how harm reduction is implemented in clinical practice that ultimately has public health implications in terms of more effectively addressing high rates of addiction that contribute to homelessness and health disparities. [Copyright &y& Elsevier]

Objective: This article addresses how consumers with dual diagnosis who were formerly homeless but are now living in supportive housing understand their recovery from substance abuse (i.e., substance abuse or dependence). Specifically, this study examined what can be learned about substance abuse recovery from consumers considered to be doing well; how past substance abuse fits into their present-day narratives; and how (if at all) policies of harm reduction versus abstinence are regarded as affecting recovery efforts. Methods: As part of a federally funded qualitative study, 38 individuals who met criteria for having achieved a measure of success in mental health recovery were purposively sampled from two supportive housing agencies, one using a harm reduction and the other an abstinence model. Researchers conducted in-depth interviews and used case study analysis, the latter including the development of case summaries and data matrices, to focus on substance abuse recovery in the larger context of participants’ lives. Results: Recovery from substance abuse was depicted as occurring either through discrete decisions or gradual processes; achieving recovery was distinct from maintaining recovery. Emergent themes related to achievement included (a) pivotal events and people, (b) maturation, and (c) institutionalization. Central themes to maintaining recovery were (a) housing, (b) self-help, and (c) the influence of significant others. Conclusions: These findings capture a complex picture of overcoming substance abuse that largely took place outside of formal treatment and was heavily dependent on broader contexts. Equally important is that consumers themselves did not necessarily view substance abuse recovery as a defining feature of their life story. Indeed, recovery from substance abuse was seen as overcoming one adversity among many others during their troubled life courses. [ABSTRACT FROM PUBLISHER]

Objective: Intensive case management (ICM) is important in psychiatric rehabilitation but there is a need to "graduate" clients. The purpose of this research was to review the literature on criteria used and outcomes of graduating clients with severe mental illness from ICM programs. Method: A systematic review conducted in 2019 used keyword searches in all major research databases. This search yielded 1,142 articles which were distilled to 20 studies that reported a graduation process from an ICM program (11 studies), and/or reported clinical or psychosocial outcomes after graduation (15 studies). Results: Three main methods have been used to determine graduation: Clinician judgment (n = 8 studies), rating scales (n = 4), or shared decision-making (n = 3). Across studies, graduation rates ranged from 1% to 25% over a 1-year period, 44% to 65% over a 2-year period, and 9% to 29% over a 4-year period. After graduation, 4%–14% of graduates had to be readmitted to ICM but 60% of studies reported positive client outcomes after graduation which included significant reductions in hospitalizations, and improvements in quality of life, unmet needs for care, and family relationships. Only two studies reported negative outcomes after graduation which included hospitalizations, homelessness, incarceration, and treatment drop-out. Conclusions and Implications for Practice: ICM programs can successfully graduate clients to less intensive services, and there are procedures available to guide graduation decisions but no universally agreed-upon method. Additional research is needed to identify optimal methods for graduation for different client populations. Impact and Implications: This review found that intensive case management programs can successfully graduate clients to less intensive services. Clinician judgment, rating scales, or shared decision-making are the most commonly used methods to graduate clients from time-unlimited case management but there is no universally used method. Various positive outcomes of graduation reported included reductions in hospitalizations and improvements in quality of life. Together, the findings suggest programs can develop graduation processes for clients with positive outcomes. [ABSTRACT FROM AUTHOR]