We recently published an article that identifies factors that could potentially impact the implementation of complex health and behavioral health interventions like the Housing First model. This study was rooted in our work with Housing First, and it might be of interest to Housing First programs seeking to overcome potential implementation or sustainability challenges. The abstract below describes the article, and the figure outlines the factors we identified that can (positively or negatively) impact program implementation. The full article can be found at this by clicking on the article's title below.
Defining the external implementation context: an integrative systematic literature review
Background: Proper implementation of evidence-based interventions is necessary for their full impact to be realized. However, the majority of research to date has overlooked facilitators and barriers existing outside the boundaries of the implementing organization(s). Better understanding and measurement of the external implementation context would be particularly beneficial in light of complex health interventions that extend into and interact with the larger environment they are embedded within. We conducted a integrative systematic literature review to identify external context constructs likely to impact implementation of complex evidence-based interventions. Methods:The review process was iterative due to our goal to inductively develop the identified constructs. Data collection occurred in four primary stages: (1) an initial set of key literature across disciplines was identified and used to inform (2) journal and (3) author searches that, in turn, informed the design of the final (4) database search. Additionally, (5) we conducted citation searches of relevant literature reviews identified in each stage. We carried out an inductive thematic content analysis with the goal of developing homogenous, well-defined, and mutually exclusive categories. Results: We identified eight external context constructs: (1) professional influences, (2) political support, (3) social climate, (4) local infrastructure, (5) policy and legal climate, (6) relational climate, (7) target population, and (8) funding and economic climate. Conclusions: This is the first study to our knowledge to use a systematic review process to identify empirically observed external context factors documented to impact implementation. Comparison with four widely-utilized implementation frameworks supports the exhaustiveness of our review process. Future work should focus on the development of more stringent operationalization and measurement of these external constructs.
Dennis Watson, Associate professor of Social and Behavioral Sciences at IUPUI, and Paul Shaw, COO at Light House Mission, talk the housing-first approach to aiding those facing homelessness. (By Sam Caravana/For IndyStar)
The opioid epidemic has affected countries across North America, with opioid overdose deaths being the number one cause of accidental deaths on the continent. The province of British Columbia in Canada has been hit particularly hard by the epidemic, and as a result, has been working to increase the number of the overdose prevention and response interventions in housing programs designed to treat those living with substance use disorder (SUD). According to a recent article by Bardwell and colleagues published in the Harm Reduction Journal, supervised consumption sites (SCS), among other interventions, have been identified as an evidence-based approach to reducing the number of overdose deaths that occur among those living in supportive housing programs .
Examples of interventions implemented in housing programs across British Columbia thus far include “housing-based overdose prevention sites, peer-led naloxone training and distribution, peer witness injection programs and shared-using rooms.” Despite the implementation of these interventions, research exploring both the effectiveness of and need for harm reduction housing interventions is limited. This is largely due to the lack of evaluation of these innovative programs. In addition, the data that is available is largely based on programs where coverage of the populations served is limited and data is context-specific.
SCS allow individuals a space to use pre-obtained drugs under the supervision of a trained health care provider, thus, ensuring safe injection practices and reversing overdose, should it occur. SCS have been shown to lower rates of overdose deaths and improve health outcomes for those with SUD. As such, there is yet to be a single overdose at any of the SCS in operation in Europe, Australia, or Canada . Overdose prevention sites (OPS) are similar to SCS in regards to the supervision of injection to prevent poor health outcomes, but OPS have been identified as “simpler in design and operation, are more peer driven, and offer no or fewer clinic services.” Both SCS and OPS have been implemented in supportive housing programs serving substance users in Canada; however, lack of governmental support in implementing and funding such programs create a barrier to increasing the number of these programs in housing locations.
As described by the authors of the article, including SCS and other prevention and response interventions as a part of housing programs “provides multiple opportunities to address overdose risk and drug-related harms.” Implementing more overdose prevention and response programs into housing programs will also provide more “flexible” interventions that can better overcome the numerous barriers and risks faced by people who use drugs. While there is a need for increased implementation of these interventions in housing programs, there is also a need for effective evaluation of these programs in order to successfully gain support from governmental agencies that may offer funding opportunities. The implementation of overdose prevention and response interventions in housing programs holds promising health outcomes for people who use drugs. With proper implementation and evaluation, the creation of such programs will be more commonplace, leading to a reduction in overdose related deaths.
Check out the following resources to learn more about a housing first model and ways to prevent and respond to an overdose:
 Bardwell, G., Collins, A., McNeil, R., & Boyd, J. (2017) Housing and overdose: an opportunity for the scale-up of overdose prevention interventions? Harm Reduction Journal, 14(77). doi: https://doi.org/10.1186/s12954-017-0203-9
 Potier, C., Laprevote, V., Dubois-Arber, F., Cottencin, O., & Rolland, B. (2014). Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence, 145, 48-68. doi: https://doi.org/10.1016/j.drugalcdep.2014.10.012
We just published an article on the development of our Housing First implementation strategy!
Alpha test results for a Housing First eLearning strategy: The value of multiple qualitative methods for intervention design
By: Emily Q. Ahonen, Dennis P. Watson, Erin L. Adams, and Alan McGuire
Detailed descriptions of implementation strategies are lacking, and there is a corresponding dearth of information regarding methods employed in implementation strategy development. This paper describes methods and findings related to the alpha testing of eLearning modules developed as part of the Housing First Technical Assistance and Training (HFTAT) program’s development. Alpha testing is an approach for improving the quality of a product prior to beta (i.e., real world) testing with potential applications for intervention development.
Ten participants in two cities tested the modules. We collected data through (1) a structured log where participants were asked to record their experiences as they worked through the modules; (2) a brief online questionnaire delivered at the end of each module; and (3) focus groups.
The alpha test provided useful data related to the acceptability and feasibility of eLearning as an implementation strategy, as well as identifying a number of technical issues and bugs. Each of the qualitative methods used provided unique and valuable information. In particular, logs were the most useful for identifying technical issues, and focus groups provided high quality data regarding how the intervention could best be used as an implementation strategy.
Alpha testing was a valuable step in intervention development, providing us an understanding of issues that would have been more difficult to address at a later stage of the study. As a result, we were able to improve the modules prior to pilot testing of the entire HFTAT. Researchers wishing to alpha test interventions prior to piloting should balance the unique benefits of different data collection approaches with the need to minimize burdens for themselves and participants.
Housing First is a harm reduction approach to supportive housing. In the United States and Canada, and increasingly throughout Europe, homeless service providers have adopted Housing First as the guiding framework at the program and community level. Programs readily embraced the idea that we should remove barriers to housing people experiencing homelessness. The low threshold admissions policy gets people into our housing programs, but it is not sufficient. As any housing provider can tell you, the work truly begins after someone gets into housing. Once a participant is housed, participants and case managers alike may find themselves wondering, “What now?”
The critical ingredient of harm reduction-based services can guide the way that we approach participants in Housing First programs and facilitate nonjudgmental conversations with them about the risky behaviors they engage in. However, our team consistently finds that the knowledge and use of harm reduction strategies are missing in many Housing First programs. For example, during the course of one of our Housing First trainings, we met a case manager working for a housing program which identifies as practicing Housing First. When the case manager was asked about harm reduction training and practice in their program, they explained that they house people who are actively using drugs but was unable to articulate harm reduction’s role beyond that.
In an attempt to understand why programs aren’t consistently practicing harm reduction, we conducted a rapid review and document analysis of the open access literature on Housing First from the United States and Canada. The results demonstrated a lack of explicit mention and informed discussion of harm reduction in the majority of the Housing First literature. This may be a contributing factor to the limited education and application of harm reduction in Housing First programs. Read the full open access article, published in the Harm Reduction Journal here: Housing First and harm reduction: a rapid review and document analysis of the US and Canadian open-access literature
James Kowalsky, blog contributor and Project Coordinator for the Midwest Harm Reduction Institute, was recently featured on an episode of the podcast, Changing the Conversation. Changing the Conversation is a podcast hosted by Jeff Olivet, CEO of the Center for Social Innovation, that discusses issues related to homelessness, trauma, mental illness, and substance use. The podcast is an excellent resource for supporting the work of social service providers and a valuable advocacy tool for innovative solutions in the field. You can listen to the episode "That's Just Good Harm Reduction" by following this link: http://thinkt3.libsyn.com/thats-just-good-harm-reduction.
As a case manager in a Housing First program, you do so many things to support participants and improve their quality of life. The average day is so busy that it’s easy to let these seemingly small tasks go by unnoticed. It’s important to recognize that all these little tasks make you an amazing helper for your participants! Here’s an opportunity for you, as an individual or with your coworkers, to celebrate the things you do to help make positive changes in people’s lives. Thanks for all you do and happy holidays!
To print the Bingo card, copy and paste the image below into a document.
There’s a common trope among social service providers—don’t work harder than the client. While this makes practical sense, as programs aim to increase participant independence, it isn’t the appropriate approach in the Housing First Model. Housing First programs are designed to support the most vulnerable, and oftentimes disengaged, members of our communities. The participants that Housing First caters to are often reluctant to engage due to histories of trauma, symptoms of mental illness, or negative experiences trying to access care.
To overcome the barriers to engagement, case managers in Housing First programs will work harder than their clients at times. A case manager may end up making numerous unsuccessful attempts to engage someone—scheduling a home visit, making follow-up calls, leaving notes, or trying to find the participant in the community. These outreach and engagement efforts are time consuming and require the case manager to be persistent and patient. Housing First values the autonomy of a client and recognizes that a case manager cannot decide whether or not someone will make changes or force them to do so. However, case managers can increase the likelihood of engagement and change by consistently attempting to reach the client in a respectful, compassionate manner.
Many Housing First programs ask that clients have regular, meaningful engagement with a case manager. This can range from weekly meetings, to one or two engagements per month, to a meeting every three months. This minimum level of engagement gives the program an opportunity to confirm the client is still occupying their apartment and check in to see if any additional supports are desired. Housing First workers should strive to express concern and offer support without making the participant feel like the program is trying to catch them doing something wrong or that they’re expected to fail.
...case managers in Housing First programs will work harder than their clients at times.
Previously, we’ve talked about reduced service requirements as a critical ingredient of Housing First programs. This presents a dilemma for Housing First programs. How can we require that someone have contact with a case manager and not require them to participate in services? Programs are torn between providing support and encouraging self-determination. Housing First programs around the country navigate these issues by balancing competing concerns in different ways. For instance, there are some programs that prioritize housing maintenance above all else and choose to mandate that clients have a representative payee so that their rent is always paid and their housing is never lost due to nonpayment. Other programs place greater emphasis on the Housing First principle of valuing the client’s perspective so that a client chooses whether or not they want a rep payee. This has been framed in the mental health recovery model as “the dignity of risk.” Providing a greater degree of autonomy and independence is noble, but also comes with the risk that the participant may fall behind in rent. If that happens, it’s the case manager’s job to communicate with the landlord and increase engagement attempts to identify the participant’s barriers to paying rent.
People also shouldn’t be penalized for getting better. Sometimes, Housing First participants will engage less often because they are doing really well. They may be busy with employment, volunteering, spending time with family, or life in general. In these cases, engagement with Housing First staff may be as minimal as a phone check-in every couple months. Between a brief check-in and a lack of complaints from a landlord or property manager, the case manager can be assured that someone is doing well enough in housing that they do not need additional support.
This demonstrates the need for “moving on” or “bridge” programs. This approach helps people transition out of Housing First programs, which provide ongoing case management using a permanent supportive housing model, but keeps them connected with ongoing housing subsidies (e.g. housing choice vouchers) by partnering with local housing authorities. When clients no longer need ongoing support, our communities should be able to link them with less intensive programs that still assist with paying the rent. This can also open the door for someone else to enter the supportive housing spot they leave behind.
Adaptations can happen with an evidence-based practice while still staying true to the model. Ultimately, agencies must make individualized choices about how to operate their Housing First programs. To determine the appropriate level of engagement, programs should consider factors like the amount of staff time available, the level of need of participants, and the Housing First principles that they want to prioritize. Housing First programs should be prepared to be flexible with clients and understand that it’s difficult to come up with a one-size-fits-all approach to any program. Although requirements to engage on a monthly basis seem like a violation of reduced service requirements, they provide an opportunity to engage with participants and ensure they have access to community supports that can help them retain housing placement. With or without a requirement, it's up to the case manager to commit to reaching out regularly and attempting to stay connected with their participants.
We’ve taken a break from blogging the past month to work on our annual conference, Harm Reduction in the House. The conference focuses on how harm reduction can be applied to improve the delivery of housing and other social services. There are a number of nuanced issues that come up for participants in programs using the Housing First Model. This year, conference attendees were able to hone in on areas to use harm reduction including safer substance use practices, sexual health promotion with tools like PrEP, and engagement strategies that promote positive changes like the SODAS Method. The conference hosted several hundred presenters and attendees from around the Midwest including Illinois, Indiana, Wisconsin, Michigan, and Ohio. In this post, we look at some of the reaction and takeaways from the conference.
The theme of this year’s conference was “Growing from Our Roots.” Harm reduction is getting into the mainstream. In recent years, a broader range of programs and providers around the world have embraced harm reduction. Growing from Our Roots is a reminder that harm reduction work began with drug users and people actually engaged in risky behaviors. Their community, respect, and self-determination drive the principles of the harm reduction philosophy in service delivery. They are experts in their own lives and must be included in the work and accompanying advocacy efforts. Daniel Raymond, policy director at the Harm Reduction Coalition, attended the conference and offers additional thoughts on this topic and more in “Holding space for the unredeemed: harm reduction and justice.”
One of the popular sessions at the conference was the “Irreverent: Harm Reduction Youth Work and Radical Ministry” workshop. Rabbi Menachem Cohen and Pastor Alli Baker led a group discussion including youth who are LGBTQ and have experienced homelessness. The conversation explored the experience of homelessness from a young person’s perspective and what providers can do to create safe, welcoming environments. When workers listen nonjudgmentally and remain flexible, they have the power to support youth in getting off the streets and remaining housed. Rev. Kathryn Ray is a member of Clergy for a New Drug Policy and offered her thoughts on this workshop after attending the conference in “Rule Breaking and Radical Love.” She discusses the way that harm reduction can open doors for people and says, “Harm reduction work is gospel work.”
We have to acknowledge that we could not put on this conference without the help of our amazing volunteers. Thanks to everyone who pitched in! Among other duties, we had volunteers live-tweeting the conference. Below are some of the highlights from the day. For a full list of tweets, check out #HousingisHR on Twitter.
Photo credit PrEP4Love.com
The fight against HIV/AIDS advanced tremendously over the last 30 years. Treatments can decrease viral loads to undetectable levels, improving the health of people living with HIV and lowering the chances of transmitting HIV to others. But, with over 40,000 new HIV infections annually in the United States there is more to be done. Additionally, people of color, trans women, and men who are gay or bisexual continue to be disproportionately affected by HIV. In response, the National HIV/AIDS Strategy increasingly promotes HIV prevention efforts.
PrEP (pre-exposure prophylaxis) is a new approach to HIV prevention. PrEP treatment means that someone who is HIV-negative can take a daily pill to reduce their risk of becoming infected with HIV. PrEP does not protect against other sexually transmitted infections or pregnancy. It is intended to be used in combination with other safer sex measures, including condoms. Truvada is the medication currently approved for PrEP treatment by the FDA. The medication must be taken for at least seven days to reach sufficient levels for protection against HIV. PrEP is recommended for anybody at high risk of HIV infection. Primarily, this includes men or transgender women who have sex with men, people who are HIV-negative but have a partner who is HIV-positive, and people who inject drugs.
Research shows people who use PrEP experience a reduction in their risk of HIV infection. Transmission of HIV has been demonstrated to drop by over 90% among people who take PrEP consistently. As explained on the website PrepFacts.org, “If you don’t take PrEP consistently it can’t protect you from HIV, but if you do take it regularly it can offer strong protection.” PrEP is sometimes confused with PEP. PEP stands for post-exposure prophylaxis and can reduce someone’s risk of becoming infected with HIV after they’ve come into contact with it. To be effective, PEP treatment must begin within 72 hours of exposure to HIV and last for a month.
It’s important for housing first providers to be informed about PrEP and PEP and to share information about these treatments with their participants. Housing first providers work with people in marginalized communities who are at a heightened risk of HIV exposure. In addition to the groups previously mentioned, HIV is more prevalent among people who are homeless. Although PrEP is highly effective, one in three health care providers haven’t heard about it. So, it’s up to service providers and other helpers in the community to spread the word about this option.
Even if a health care provider is aware of PrEP, they might be too rushed to fully understand what’s going on with their patient or stigmatize their risky choices. The Housing First Model gives service providers the time needed to get to know someone and find out about potential risks they face. If housing first providers are using a harm reduction approach, they are more likely to get honest information about a participant engaging in unprotected sex or injection drug use. That means that they might be aware of a person’s heightened risk for getting HIV and can bring PrEP to someone’s attention, who may not hear about it otherwise.
Sex feels good. It helps satisfy our need for intimacy and connection. People do it despite the risks of unwanted pregnancy or sexually transmitted infections. As with all harm reduction work, staff's goal is to help people strategize how to get the benefits from a behavior without experiencing the consequences. Creativity is a necessity when service providers are collaboratively building a menu of options to reduce harm in their participants’ lives. But, that creativity can be stifled when staff try to talk about sex and participants respond by saying that they will never use condoms or that they are HIV-positive and sexually active. Don’t be deterred! Just because a person isn’t willing to do something in the safest way possible, doesn’t mean that they won’t consider other strategies that may help. Instead of using fear to motivate decision making, the focus should be on education, options, and empowerment. These values are reflected in many of the public health campaigns promoting PrEP which are more focused on being sexy than scary. Getting comfortable talking about risky sexual behaviors and the pleasure people get from their sex lives positions case managers to introduce options like PrEP to their participants in an appealing way.
Here are some additional resources for learning about PrEP. Check out this website for information on where to find PrEP in your area. PrEP is covered by most insurance providers and Medicaid. For more details about how to get PrEP, including links to available payment assistance programs, go to prep4love.com created by the AIDS Foundation of Chicago. Prepfacts.org was created by the San Francisco AIDS Foundation and includes a detailed list of frequently asked questions. The Well Project focuses on women’s health to address HIV/AIDS and presents a balanced overview of PrEP in the article “PrEP for Women”. On September 23rd the Midwest Harm Reduction Institute will be hosting a presentation on PrEP at the annual Harm Reduction in the House Conference in Chicago. Consider attending the conference or following the hashtag #HousingisHR to keep up with the conference.