The objective of this section of the Implementation Module is to highlight one of the At Home/Chez Soi project teams that demonstrated a very high level of fidelity to the Housing First model, while effectively adapting the program to their local context.
The Vancouver RainCity Assertive Community Treatment (ACT) team was able to maintain high fidelity to the program model, even under its unique circumstances, where a non-governmental organization (NGO) was the agency providing and a housing support program. The highlights in this section of the module were informed by interviews conducted with three key informants that were engaged in implementation of the Vancouver RainCity ACT team’s program.
About Vancouver Raincity
Implementation highlights from the Vancouver RainCity ACT team
First of all, key informants from Vancouver RainCity’s ACT team were asked, “To what do you attribute the high fidelity to the Housing First model your team was able to achieve? What makes RainCity ACT such a strong team?” Based on three interviews, key informants attributed the high fidelity the team was able to achieve to: team leadership; teamwork; commitment to the Housing First model; a strong sense of social justice; effective technical assistance; and a flexible organizational/bureaucratic structure.
Team leadership, teamwork, commitment to the Housing First model, and a strong sense of social justice were some of the key themes that emerged from the interviews. Informants expressed tremendous praise for the team leader of the RainCity ACT team. They emphasized his dedication to and curiosity with the Housing First model, which compelled him to read and learn a lot about the Pathways Housing First model. Furthermore, it seemed that his personal values were a fit with the Housing First model, so he was able to lead the team and support it from a strong knowledge base and with a deep commitment to implementing Housing First according to the principles — he truly believed it was possible and so did his team. Furthermore, the team leader was flexible and calm in his approach — he embraced new ways of working with people in situations that could have created anxiety for many. The team leader understood the importance and value in hiring the “right” people — those that had worked with people with complex needs before, and believed strongly in Housing First principles, such as use of harm-reduction and recovery-orientation strategies. He was supported by a Human Resources structure that gave them the ability to hire staff teams who came with similar values and became champions of the Housing First model. He hired highly organized and skilled people that complemented each other’s roles and strengths and were keen to learn from one another; effective teamwork was fundamental to the team leader and team members. Peer support was an integral aspect of the implementation process for the RainCity ACT team, and the team leader and team members highly valued the peer specialist on the team. Furthermore, the team psychiatrists were hired early in the process, were committed to the fidelity scale, and were recognized as being highly committed to their non-traditional psychiatric role on the team in working with team members and program participants. Overall, the team was highly committed to the participants, willing to do what was needed to house, rehouse, and support participants. They were willing to be creative and committed to finding solutions to the best of their abilities. Their strong beliefs about social justice and their understanding of how systemic issues faced by clients called for team members to minimize their levels of control and coercion as much as possible, but instead, to allow people high levels of choice and opportunities to find their own path to recovery.
“Excellent” technical assistance (including training, fidelity checks, telephone consultations, and in-person assistance) provided by the Mental Health Commission of Canada (MHCC) and Pathways to Housing was attributed to the high fidelity to the Housing First model achieved by the RainCity ACT team. The effective technical assistance helped the team “stay on track” when they had difficult issues to resolve. One key informant said, “Pathways really helped us learn how to be clinically responsible but also accountable to the personal recovery of our participants.”
Finally, the flexible organizational/bureaucratic structure of the RainCity ACT team was attributed to the high fidelity and adaptability to the Housing First model. The organization functioned through a fairly flat bureaucratic structure and there was a very flexible policy structure in place. Teams were given a lot of freedom to be creative and respond quickly to participant needs. For example, there was flexibility and assistance around money management, driving participants in team members’ cars, giving participants cigarettes, and buying coffee for participants.
Next, key informants from Vancouver RainCity’s ACT team were asked, “What were the challenges and strengths that RainCity as an NGO was able to bring to the implementation process?” During the three interviews, key informants discussed challenges around: experience in operating clinical teams; the size of the host agency; access to information; acquiring funding; ensuring flexibility of union contracts; quick intake of participants; ensuring appropriateness of participants; and working in multidisciplinary teams. The strengths included: flexible bureaucratic organizational and policy structures; commitment to the Housing First philosophy and principles; team leadership, and teamwork within and across teams.
One of the challenges for the RainCity ACT team was their lack of experience in operating full clinical teams. Dealing effectively with the pressure of being a non-traditional agency (an NGO) working within a clinical/health-related infrastructure was challenging. Therefore, since they did not have the type of infrastructure that organizations operating clinical teams typically have, they did a lot of extra work during the early stages of planning implementation to develop appropriate infrastructure that would effectively support their clinical teams.
Another challenge for the RainCity ACT team was the size of the NGO. Since it was a smaller agency, the team had to draw heavily on effectively accessing other resources. An additional challenge for the ACT team was that they did not have access to the Health Authority’s clinical database, which limited information sharing throughout implementation of the program. Other challenges included acquiring enough funding to be able to socialize with participants to build trusting relationships (e.g., taking them to the movies); ensuring the flexibility of union contracts for staff members; dealing with very quick intake of participants into the program; ensuring appropriate fit between participant needs and program goals; and learning to work effectively in multidisciplinary team settings.
One of the strengths that RainCity as an NGO was able to bring to the implementation process was a flexible bureaucratic organizational and policy structure. The organization already had an inherent learning philosophy, one that encouraged members to be reflective in their practices and strive toward innovation. The team perceived fidelity assessments as a chance to improve their practice, rather than as a threat to their program. One informant stated, “There was strong support for the ACT team from all levels of the organization, from the Executive Director, Associate Directors, ACT team leadership, ACT staff, and other staff and leaders within the agency.” Flexibility of the Human Resources Department of the organization allowed for recruitment of staff and leadership teams that worked well with the Housing First model. Furthermore, RainCity’s strong commitment to the Housing First philosophy and principles around recovery orientation and harm reduction was viewed as an asset to implementation. Team members did not believe stereotypes about the populations they worked with, but they strongly believed in people’s potential to recover, to make choices in their own lives, and to integrate effectively within society.
Other strengths included the degree of investment that the team leader made to working through challenges with his team and project participants; the team’s commitment to learning from each other and ability to navigate processes with different levels of training; and collaborative relationships and cross-team support made between the ACT team and the other support teams in Vancouver.
Key informants from Vancouver RainCity’s ACT team were asked, “What other information do you think those implementing a Housing First program need to know about?” Below are the key messages paraphrasing or directly quoting key informant suggestions about implementing a Housing First program. Key messages are related to Housing First principles and values, ensuring a commitment to problem-solving, Housing First model fidelity and adaptation, and housing and rehousing suggestions.
Housing First Principles and Values
- People have to come to the table with similar values and principles, and their actions must align with their values.
- Training and technical assistance helps solidify the core values and principles of the Housing First model. Expectations about values and principles must be made clear. Information about recovery-oriented, client-oriented, and harm-reduction practices must be emphasized. A commitment to understanding the complexity of people’s lives is essential.
Commitment to Problem Solving
- The team environment must allow for different people to come to work together and develop strong relationships with each other. There needs to be a commitment to problem solving and blame avoidance.
- The team leader must be committed to being removed enough from the team to hold a neutral and problem-solving-oriented approach.
Housing First Model Fidelity and Adaptation
- “For us, being part of a research study, being held to a fidelity scale and being provided with technical assistance was critical. Finding a ‘critical mass’ of internal champions who are really curious about the model and a good fit for its values is also critical…It’s also worth mentioning that the model of ‘Housing First’ is often used in a vague way, so its helpful to use the housing first fidelity scale that was created by Pathways and the MHCC.”
- Implementation processes are not perfect. Learning to adapt and be flexible and creative while maintaining program fidelity is important.
Housing and Rehousing Suggestions
- Avoid being punitive or coercive with participants. Participant choice (including housing choice) is fundamental to Housing First implementation. Engage with participants and be creative in your approach so that participants are satisfied with their choices.
- Providing a housing subsidy is essential.
- “If the Housing First scattered-site model is new to your area, you may find it is a significant departure from how services are typically delivered, and it may well be challenging to implement the model in a high fidelity way.”
- “In Vancouver there was significant skepticism from the mental health and housing sectors about offering homeless people the opportunity to go directly into independent apartments; you may find this too and need to work through it.”
- Rehousing is an important part of the implementation process. The number of times a participant will be rehoused varies between individuals. Some participants will never go through the process of rehousing. Try to develop preventative strategies to avoid the need for rehousing, and if/when it does occur, embrace participants as partners in the process.