The study design is a cohort study with a propensity score-matched control group and difference-in-difference analysis to evaluate intervention effectiveness. A hybrid type 1 effectiveness-implementation study framework is used that incorporates mixed methods to determine clinical effectiveness and explore implementation and participant well-being. Participants are selected based on their utilization of health services. Selection favoured those individuals with the most health service utilization. A control group will be created by selecting individuals from administrative hospital records that are propensity-score matched to the individuals in the treatment group (1:4 pair). The hybrid type 1 effectiveness-implementation study framework was used to guide the selection of study aims and outcomes to focus primarily on clinical effectiveness, while also exploring implementation-related factors. The primary objective of the study is to evaluate the impact of the Initiative on the number of emergency department visits and days spent in the hospital. The secondary objectives are to 2) evaluate the impact of the Initiative on program participants' health and well-being, 3) evaluate the implementation of the Initiative and assess program fidelity and barriers, and 4) to calculate the cost avoidance and cost-effectiveness of the Initiative.
The Housing Initiative is part of standard care and is not contingent on participating in any research activities. Patients that participate in the Housing Initiative will have the option to participate in the research study.
To qualify for housing through the initiative, patients must have had 2 or more inpatient admissions or 6 or more visits to the emergency department in the past 6 months. They must also either identify as Indigenous or be currently without housing, which is defined as having spent at least one night in a shelter or having received assistance from city-funded street outreach providers in the past 90 days. Historically marginalized groups, including people with disabilities, women, gender-diverse individuals, and Indigenous people, are given priority for housing. Eligible patients are prioritized for housing offers based on their use of the University Health Network emergency departments in the past year.
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Parallel
Social Medicine Housing Initiative
BehavioralThrough the Social Medicine Housing Initiative, patients will receive access to permanent supportive housing and support services based on a social medicine model. The Housing Initiative provides a housing-first approach which offers housing to individuals without prerequisites (e.g., requiring cessation of substance use, adherence to treatment). Housing will be provided through a rent-geared-to-income model, with participants paying up to 30 percent of their income towards rent. Participants will also be provided with customized social and medical support within and beyond the University Health Network, tailored to their specific needs and preferences. Patient care will be a collaborative effort involving the housing provider, the Social Medicine team, and community agencies.
Number of emergency department visits
The primary objective of the study is to evaluate the impact of the Social Medicine Housing Initiative on the number of emergency department visits for University Health Network super utilizers compared to a propensity score-matched cohort. It is hypothesized that study participants who participate in the Housing Initiative will show a reduction in acute care utilization (emergency department visits) during the 30-month outcome ascertainment period.
Days spent in the hospital
The primary objective of the study is to evaluate the impact of the Social Medicine Housing Initiative on the number of days spent in the hospital for UHN super-utilizers compared to a propensity score-matched cohort. It is hypothesized that study participants who participate in the Housing Initiative will show a reduction in acute care utilization (in-patient hospital days) during the 30-month outcome ascertainment period
Tenant Health status
A "Tenant Well-being Survey" was created using validated scales from the Massachusetts Behavioral Risk Factor Surveillance (BRFSS) questionnaires. The Well-being Survey will first be administered to the study participants at baseline and again at (approximately) month 8, month 16, month 30, and if/when a participant chooses to leave the program. The "Tenant Well-being Survey" will include 10 self-reported questions related to the health of tenants, including perceived access to health care, number of days their health was not good in the past month, barriers to accessing health care ( e.g. transportation, cost appointment scheduling), and preferred location to accessing health care services). Scores will not be aggregated for the health care measures.
Tenant Mental health
A "Tenant Well-being Survey" was created using validated scales from the Massachusetts Behavioral Risk Factor Surveillance (BRFSS) questionnaires. The Well-being Survey will first be administered to the study participants at baseline and again at (approximately) month 8, month 16, month 30, and if/when a participant chooses to leave the program. The "Tenant Well-being Survey" will include 9 self-reported questions related to the mental health of tenants, including: a scale of how many days they felt anxious in the past 30 days, a scale of how many days they felt depressed in the past 30 days, if they have received professional counselling for their mental health, barriers to accessing mental health care ( e.g. transportation, cost appointment scheduling), and perceived access to informal support systems. Scores will not be aggregated for the mental health care measures.
Tenant Substance Use
A "Tenant Well-being Survey" was created using validated scales from the Massachusetts Behavioral Risk Factor Surveillance (BRFSS) questionnaires. The Well-being Survey will first be administered to the study participants at baseline and again at (approximately) month 8, month 16, month 30, and if/when a participant chooses to leave the program. The "Tenant Well-being Survey" will include 7 self-reported questions related to the substance use, including: number of drinks in the past 30 days, number of overdoses in the past 30 days, impact of substance use on important activities, and use despite negative consequences. Scores will not be aggregated for the mental health care measures.
Tenant history of violence
A "Tenant Well-being Survey" was created using validated scales from the Massachusetts Behavioral Risk Factor Surveillance (BRFSS) questionnaires. The Well-being Survey will first be administered to the study participants at baseline and again at (approximately) month 8, month 16, month 30, and if/when a participant chooses to leave the program. The "Tenant Well-being Survey" will include 2 self-reported questions related to experiences of violence in the last 6 months and 1 self-reported question on history of sexual violence in the last 6 months.
Health care expenditure analysis
The study aims to look at the impact of the program on those that receive the resources from the program, to determine if the cost of the program is justifiable considering the reduction in healthcare utilization. Cost data will be obtained from the Institute of Clinical Evaluative Sciences of Canada (ICES) on hospital health service cost reports. These databases can also be used to estimate healthcare costs for health services covered by the government using validated individual-level costing algorithms that combine the frequency and intensity of resource utilization with a weighted per unit cost. It is hypothesized that the Initiative will reduce the cost-burden incurred by the health system from serving the study participants.
Cost effectiveness analysis
The study aims to look at the impact of the program on those that receive the resources from the program, to determine if the cost of the program is justifiable considering the reduction in healthcare utilization. Cost data will be obtained from the Institute of Clinical Evaluative Sciences of Canada (ICES) on hospital health service cost reports. These databases can also be used to estimate healthcare costs for health services covered by the government using validated individual-level costing algorithms that combine the frequency and intensity of resource utilization with a weighted per unit cost. A cost-effectiveness analysis will be conducted based on the costs of the Initiative compared to cost avoidance within the health care system. It is hypothesized that the cost of providing the Initiative will be less than the cost-saved from the reduced health system utilization created by it.
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