Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Discus Amsterdam: Housing First Evaluation © UMC St Radboud Maart 2012 Judith Wolf, Marjolein Maas, Sara Al Shamma, Dorieke Wewerinke

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Contents •Discus Amsterdam: Housing First •Research objectives & study components •Discus clients: selection criteria •Profile of clients •Main outcomes: Health, social contacts, Quality of life, residential stability, rates of nuisance, perceived benefits (satisfaction with Discus and QoL improvements), fulfilment of expectations •Policy implications •Future implementation

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Discus Amsterdam: Housing First (Pathways to Housing, Tsemberis, 1992) •Target group: roofless people •Independent accommodation (dependent rent contracts) •Housing accommodation dispersed throughout city •Rehabilitation approach: focus on individual strengths

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Selection criteria for Discus Amsterdam: Housing First 1.Be motivated 2.Cause no nuisance 3.Pay the rent 4.Accept at least one home visit per week by the housing support worker 5.Agree to income management 6.Comply with the Discus behavioural rules

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Evaluation: objectives and study components (Commissioned bij HVO Querido, City of Adam, Agis Health Insurance Company) Gain insight into:  Profile of participants  Health  Social contacts  Quality of life and QoL improvements  Residential stability  Rates of nuisance  Perceived benefits from Discus: - QoL improvements - Satisfaction with Discus Study period: –  One semi-structured, face-to-face interview with clients (use of standardized instruments)  Completion of interview questionnaires by support workers  Group interview with support workers  Analysis of nuisance data recorded by housing associations and Discus Study period: –  One semi-structured, face-to-face interview with clients (use of standardized instruments)  Completion of interview questionnaires by support workers  Group interview with support workers  Analysis of nuisance data recorded by housing associations and Discus No conclusions can be drawn as to whether Discus is better than other types of housing provision.

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Profile of Discus customers 84 customers registered with Discus between Dec Feb 2011; 64 participants in study, response rate 80%  78% male, average age 45 (range: 24 to 62)  55% of ethnic minority background, 74% non-Western  41% primary or no education  80% unmarried  88% single  48% had children, 65% had 1 or 2 children  94% lived partly or wholly from social benefit, 72% from social assistance  41% were in paid employment or voluntary work  Average monthly disposable income: €208  70% in debt → €13,000 on average (range: €100 to €120,000)

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Health  Self-appraisal of physical and mental health: reasonable to excellent: 67% (physical), 80% (mental)  52% had physical health problems, 45% had long-term health problems, 45% were currently in treatment  Higher rates of mental health problems (anxiety, depression, psychosomatic symptoms, hostility) in comparison to Dutch general population  ≥ 50% reported past-month use of ≥ 5 daily units of alcohol, cannabis, crack or powder cocaine, or methadone / LAAM / buprenorphine Indication of vulnerability: lifetime use of mental health services  52% outpatient addiction treatment  52% inpatient addiction treatment  64% outpatient psychiatric treatment  42% inpatient psychiatric treatment

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Social contacts Visits within personal network:  Family: 40% at least once a month, 29% never  Friends and acquaintances: 52% at least once a month, 24% never LonelinessDiscus- customers Dutch population Not lonely25%68% Average loneliness47%28% Rather lonely23%3% Extremely lonely5%1%

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Quality of Life (scale 1-7: ‘terrible’ to ‘delighted’) General quality of life reported high: average score 5.0 Highest satisfaction rates: Household maintenance and self-care: 5.7 Sense of safety: 5.7 Accommodation: 5.4 Emotional health: 5.4 Social functioning: 5.4 Resilience: 5.4 Relatively lower satisfaction: Finances: 4.4 Relations with family: 4.6 Relations with offspring: 4.0

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Residential stability Customers registered with Discus between inception in 2006 and 6 April 2011: n = 123 Still housed with Discus Support: 77% (n = 95) No longer participating: 23% (n = 28) - 7 had independent rent contracts - 10 transferred to different type of housing provision - 3 departed due to severe nuisance - 8 departed for other reasons: 3 died, 1 withdrew voluntarily, 1 returned to family abroad, 3 entered prison

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Rates of nuisance ( ) Complaints to housing associations:  26 nuisance complaints for 100 flats Most complaints were by neighbourhood residents, most were about noise. Complaints to Discus:  41 complaints, 75% involving mild to moderate nuisance Discus takes up the complaints, but precise outcomes are not always clear. Needs improvement.

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Perceived benefits from Discus: QoL improvements

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Perceived benefits from Discus: Satisfaction Satisfaction: Average score: 8.2 (1-to-10 scale) 69%: expectations fulfilled, satisfaction with outcome – ‘Things are going great.... I’m satisfied with my flat. Discus recognises my problems and accepts me the way I am.’ – ‘I’ve improved 99 per cent. I hadn’t expected that.’ 19%: expectations partly fulfilled – ‘I’m much more independent. It’s succeeded halfway. I’m still in debt, unemployed and not financially stable.’ 12%: expectations not fulfilled, outcome below expectations – ‘I’m disappointed. I’ve got no job. I believed that if I got a flat, I’d soon get a job, but things were different in practice. My social life is also not as good as I had hoped.’

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Conclusions  Discus reaches a severely deprived group: people with weak socioeconomic status, multiple problems and high use of social and health services (past and present).  High satisfaction rate with Discus: a score of 8.2  High quality of life and high rates of perceived improvements in many life domains  Relatively low rates of nuisance complaints  After 5 1/2 years of Discus, the majority of clients (77%) were still housed with Discus support and the real dropout rate was low (2.4%).  Discus Amsterdam is successful!

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Policy implications  Parties concerned (HVO Querido, municipality of Amsterdam, and a health insurance company) want to continue policy of extramuralisation  Invest in Housing First: health insurance company already agreed on budget for 240 extra care packages for Housing First (commitment is 300 or more)  In collaboration with housing associations 240 houses have to be made available for Housing First (and possibly more).

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Future implementation  Further development of strength based aproach, own direction and rehabilitation  Continued investment in (new) workers;  Focus on consensus within and between teams to assure internal quality  Practice based learning: reflecting on practice, developing procedures and annually assessing necessary adjustments

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Thanks are due to Customers of Discus Discus housing support workers Members of the advisory committee: Wessel de Vries, Noor Bertens, Paul van Dijk and Nienke Boesveldt Research team: Sara Al Shamma, Marjolein Maas, Nicoline Jansen, Astrid Altena and Judith Wolf Interviewers

Onderzoekscentrum maatschappelijke zorg “gedreven door kennis, bewogen door mensen” Onderzoekscentrum maatschappelijke zorg Thank you for your attention. Any questions? Discus: Wessel de Vries: UMC St Radboud: Judith Wolf: