Healthcare

The journey to social inclusion: Exploring evidence based solutions to end homelessness

14 Jul 2015, by test test

Sacred Heart Mission imageWith over 20 years’ experience in her sector, Cathy Humphrey, CEO of the Executive Team at St Kilda’s Sacred Heart Mission is a strong believer that “there is no one-size-fits-all model to solving homelessness. Support needs to be individualised with evidence showing that understanding the casual factors that lead to homelessness can provide effective intervention to sustain peoples permanent exit from homelessness. As a preview to her presentation at the biennial Homelessness Summit in Sydney, Cathy shared some of the positive and thoroughly researched findings of the Sacred Heart Mission’s recent Journey to Social Inclusion (J2SI) program.

Is ending homelessness as simple as providing housing and accommodation?

For some people, yes.

But there are many people with complex mental health issues, trauma and substance misuse issues that require much more than just a roof over their head. Many Sacred Heart Mission clients fit in to this group.

Our Journey to Social Inclusion (J2SI) program provides a rigorous evidence base for how stable housing in addition to intensive, three year support can end homelessness.

Reducing homelessness across Australia requires an approach that takes the evidence from research and home grown pilots and translates this into evidence based solutions. Studies such as ‘Journeys Home’, a longitudinal study of factors affecting housing stability, Dr Guy Johnson’s study of pathways in and out of homelessness, and pilots studies such Sacred Heart Mission’s, Journey to Social Inclusion Pilot (J2SI), all provide longitudinal evidence that looks to understand the casual factors that lead to homelessness and effective interventions to sustain peoples permanent exit from homelessness.

Examining the results of these studies and my 22 years of working in the sector, tells me that we need a range of responses from short term crisis intervention for the first time homeless through to intensive support models to overcome a life time of chronic homelessness to long term supported accommodation for people who have enduring needs.

Affordable housing is critical to ending homelessness. But some people need support to sustain that housing, otherwise we will continue to see the churn of repeated periods of homelessness.

Currently our services system is very crisis driven, with 3 month of support expected to end person’s homelessness. Support and accommodation has to be tailored, individualised and assertive in nature. Too often, in particular at chronic end of homelessness, people do not exhibit help seeking behaviours. The service system needs to take responsibility for creating the service relationship through assertive and opportunistic engagement at drop in services and meals programs.

Long-term and chronic homelessness presents quite different challenges to other types of homelessness: the effects on the individual, society and economy are costly and complex and the cycle is harder to break the longer the person has been trapped in cycles of homelessness.

From a practice perspective Sacred Heart Mission’s J2SI pilot found that a sustained trusting relationship by a service that operates from a trauma informed perspective is critical, alongside rapid access to safe affordable housing. Still, there is no one-size-fits-all model to solving homelessness: any solution must be individualised, with support wrapped around the person.

What were some of the outcomes and achievements of the Sacred Heart Mission’s Journey to Social Inclusion (J2SI) project?

Sacred Heart JSI picFindings from Sacred Heart Mission’s four year study on homelessness J2SI, show that the cycle of long-term homelessness can be broken. The J2SI pilot independently evaluated by RMIT and Melbourne University is the first of its kind to undertake a longitudinal randomised control study, that measured a pilot group of 40 J2SI participants against a control group of 43 participants who received existing services. This is unique, as most studies evaluate the success of the pilot against a general population sample. This approach demonstrates the effectiveness of J2SI compared to the ‘as is’ services system.

The evaluation shows that an intensive service delivery model can be very effective when working with the long-term homeless, although there are still project design and methodological issues to confront.

One year after the completion of J2SI program support, 75% of J2SI participants remained in stable housing. At the same time, outcomes of the control group increased. This may in part be due to positive selection bias: evaluators were only able to contact and meet with the relatively stable people within the control group.

While some participants’ gains eroded after the program’s completion (36 month report showed improved physical health, decreased use of welfare, homelessness and expensive health services, as well as the amount of time incarcerated), twelve months post service delivery there remained strong measurable outcomes such as:

  • Psychiatric service use : over 66% decline in usage rates for both emergency presentations

and admission to psychiatric units among J2SI participants

  • Self-reported health: J2SI participants reporting no bodily pain increased from 27% to 45%
  • Health service use:
    • 80% decline in emergency hospital services use (compared to 21% increase in control group)
    • 80% decline in average number of days hospitalised (compared to 33% reduction in control group)
  • Mortality rates : J2SI participant rates were half (2) those of control group (4)

Given that limited resources are a core challenge for NFPs, it’s understandable that service delivery frameworks reflect these funding arrangements. How important is that frameworks instead focus on the needs of participants, especially given that frameworks inevitably face a cost benefit analysis?

It is crucial that any service delivery frameworks reflect first the need of participants before the requirements of government.

The J2SI pilot shows that with the right investment, significant breakthroughs can be delivered and measured in order to inform the bigger picture issue, of homelessness across Australia. By holistically addressing the root causes that lead to the person’s first pathway into homelessness alongside taking the time to address the issues that have kept people trapped in homelessness, results in significant reduction in the use of costly, emergency health services and are placing less strain on public services and government.

While the first pilot’s evaluation shows that if a strictly economic analysis is performed, incorporating a value on the lives saved is required to justify program costs, we are confident that this is a major step toward a developing a solid evidence base on how to address chronic homelessness.

Overall, the Benefit-Cost ratio is $0.19 for government, $0.25 for society, and $1.32 when the economic value of lives saved was taken into account. A Benefit-Cost ratio of $1.32 means that for every dollar spent there is a return of $1.32.

An alternative analysis of the J2SI Pilot data one year post service delivery suggests that the program creates cost savings to government of around $70,365 per participant ($17,591 per year). We come to this number by setting aside the control group and comparing the cost to government of servicing J2SI participants at baseline, with that same cost at the 48-month mark.

Applying such a rigorous economic evaluation of this program has been a very ambitious undertaking, especially given some of the direct social outcomes are intangible. While many measurable, material aspects of clients’ lives have improved, our theory of change suggests that the evaluation ought to be more interested in qualitative, subjective matters that are inherently hard to measure and compare between groups.

When Australian Government White Paper on Homelessness, ‘The Road Home’ was released in 2008, one of the stated goals was to halve overall homelessness by 2020. In your view, what more is needed to get closer to realising this goal?

As Government reform unfolds we have to be careful that demand and market driven approaches are not seen as the Holy Grail and the solution for ending homelessness. Consumer driven care may work in mainstream disability and aged care, where there is often strong advocacy capacity of family or friends to ensure access to services and drive the care package, but for those where society and the market has failed them, where there is total absence of family advocacy or a next of kin, we may see people further marginalised and slipping through the safety net. This is the case among the chronic homeless population perhaps more than any other.

Statistically homelessness across Australia is increasing. Until we can grapple with the underpinning issues of affordable housing supply, poverty, and fixing a crisis orientated service system, reducing homelessness will remain a challenge.

We need brave governments at all levels to drive the political will required to tackle major reform in this area. Organisations like Sacred Heart Mission are prepared to invest in evidence based solutions as are many others, but we cannot continue to do this alone. Government needs to be at the table to sustain and invest in the innovation that will lead to tangible and realistic targets to reduce homelessness.

For copies of the J2SI evaluations, see www.sacredheartmission.org.

Cathy will be speaking at the biennial Homelessness Summit in Sydney on Wednesday 22nd July 2015. To follow the Sacred Heart Mission’s activities, visit the Sacred Heart Mission at www.facebook.com/sacredheartmission

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