When I can't help, I suffer: A scoping review of moral distress in service providers working with persons experiencing homelessness.

Background: Service providers are experiencing mental health decline as they work to meet the needs of persons experiencing homelessness in a system that constrains their ability to help. Although moral distress is widely recognized in health care, the experience of moral distress in service providers working with people experiencing homelessness has not been explored in a scoping review.

Aim: To identify the range and nature of literature on moral distress among service providers working with persons experiencing homelessness.

Programmatic and Organizational Barriers and Facilitators to Addressing High-Risk Issues in Supportive Housing and Housing First Programs.

Risk management is an important component of service delivery in supportive housing and Housing First programs. However, there is no evidence on the implementation of risk management approaches in these settings. This qualitative study examined what service providers working in supportive housing and Housing First programs in Canada identify as the programmatic and organizational factors that affect the prevention and management of high-risk behaviours and challenges (e.

Antecedents and Consequences of Violence in Homeless Shelters: Perspectives and Experiences of Service Users and Shelter Staff.

Violence is a critical issue in homeless shelters that affects service users and staff, yet there is limited evidence on how shelter-based violence occurs. The objective of this qualitative study was to investigate the antecedents and consequences of shelter-based violence from the perspectives of service users and staff. Purposive sampling was used to recruit individuals experiencing homelessness and shelter staff in a large metropolitan city in Ontario, Canada.

Service restrictions from emergency shelters among people experiencing homelessness: Uncovering pathways into unsheltered homelessness and institutional circuitry.

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review.

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized.

Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis.

The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters.

A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness.

Objective: Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto.

Methods: The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge.

Towards the Quadruple Aim in permanent supportive housing: A mixed methods study of workplace mental health among service providers.

The Quadruple Aim is a health policy framework with the objective of concurrently improving population health, enhancing the service experience, reducing costs and improving the work-life of service providers. Permanent supportive housing (PSH) is a best practice approach for stably housing people experiencing homelessness who have diverse support needs. Despite the intervention's strong evidence base, little is known about the work-life of PSH providers.

Shelter Bans Among People Experiencing Homelessness: an Exploratory Study of Predictors in Two Large Canadian Datasets.

Emergency shelters are a core component of homeless service systems that address immediate basic needs. Service bans, which refer to temporary or permanent disallowances from a program or organization, are an underresearched phenomenon that can leave people experiencing homelessness without needed supports. This exploratory study examined the factors associated with shelter bans among people experiencing homelessness using secondary data from two Canadian studies: (1) a multisite randomized controlled trial of Housing First (At Home/Chez Soi Demonstration Project) and (2) a cross-sectional survey of youth experiencing homelessness across Canada (2019 Without a Home-National Youth Homelessness Survey).

Gains and losses within the homeless service, supportive housing, and harm reduction sectors during the COVID-19 pandemic: A qualitative study of what matters to the workforce.

The COVID-19 pandemic has had deleterious effects on individuals experiencing homelessness; yet, less is known about how this global health crisis is impacting service providers that support the homeless population. This qualitative study examined the perceived impacts of the COVID-19 pandemic on the lives and work experiences of service providers in the homeless service, supportive housing, and harm reduction sectors in Canada. Further analyses were conducted to identify the occupational values that were represented in the work-related changes experienced by providers.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada.

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services.

Cycles of instability: Proximal and distal influences on residential instability among people with histories of homelessness in three Canadian cities.

People with histories of homelessness often have difficulties obtaining and maintaining adequate housing. This qualitative study examined the residential transitions of people with histories of residential instability and homelessness to understand factors contributing to the instability they experience. Interviews were conducted with 64 participants about their housing transitions, in the final year of a 4-year, prospective cohort study in three Canadian cities (Ottawa, Toronto, and Vancouver).

Workplace trauma and chronic stressor exposure among direct service providers working with people experiencing homelessness.

Background: Service providers working with people experiencing homelessness can be directly and indirectly exposed to trauma and other chronic stressors in their work. The types of individuals that are most at-risk of problematic outcomes from traumatic event exposure are unknown.

Aim: This study examined exposure to and effects of workplace traumas and stressors among service providers working with people experiencing homelessness in Canada.

Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review.

Background: Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First.

Methods: A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar.

Mental Health and Wellness of Service Providers Working with People Experiencing Homelessness in Canada: A National Survey from the Second Wave of the COVID-19 Pandemic.

Objective: This study examined the scope of common mental health problems and perceived impacts of the COVID-19 pandemic among direct service providers working with people experiencing homelessness in Canada.

Method: This cross-sectional study used an online survey that was disseminated to homeless service, supportive housing, and harm reduction organizations and networks. Data were collected on depression, anxiety, stress, post-traumatic stress, compassion satisfaction and fatigue, and substance use problems as well as pandemic-related changes in mental health and wellness.

The use of eHealth interventions among persons experiencing homelessness: A systematic review.

Objective: eHealth interventions are being developed to meet the needs of diverse populations. Despite these advancements, little is known about how these interventions are used to improve the health of persons experiencing homelessness. The aim of this systematic review was to examine the feasibility, effectiveness, and experience of eHealth interventions for the homeless population.

A Multilevel Intervention Framework for Supporting People Experiencing Homelessness with Pets.

Approximately one in 10 people experiencing homelessness have pets. Despite the psychosocial benefits derived from pet ownership, systemic and structural barriers can prevent this group from meeting their basic needs and exiting homelessness. A multilevel framework is proposed for improving the health and well-being of pet owners experiencing homelessness.

Finding home: Community integration experiences of formerly homeless women with problematic substance use in Housing First.

Aims: This study explored community integration among women participating in a Housing First program. Physical, social, and psychological dimensions of community integration were examined.

Methods: This study used neighborhood walk-along and photo-elicitation interviews to explore 16 formerly homeless women's experiences of community integration.

"It's not just injecting drugs": Supervised consumption sites and the social determinants of health.

Background: People who inject drugs are highly vulnerable to social determinants of health (SDOH) inequities, such as homelessness, food insecurity, lack of social support, and poor access to healthcare. Supervised consumption sites (SCSs) have been developed to reduce harms associated with injection drug use but their social impacts remain largely unknown. This study explored service users' experiences with SCSs and how their service use affected their SDOH.

Service use and recovery among currently and formerly homeless adults with mental illness.

Background: A range of health and social services exist to address the many life adversities experienced by people with mental illness. However, the effects of services on their recovery in the context of ongoing homelessness and poverty have been minimally examined.

Aims: This qualitative study sought to better understand the role of health and social services in the recovery processes of people with mental illness and histories of homelessness.

Effectiveness of Housing First for Homeless Adults with Mental Illness Who Frequently Use Emergency Departments in a Multisite Randomized Controlled Trial.

Frequent emergency department (ED) users experiencing homelessness are associated with high costs for healthcare systems yet interventions for this group have been minimally investigated. This study used 24-month data from a multisite randomized controlled trial of Housing First (HF) to examine how effective the intervention is in helping frequent ED users with a mental illness to achieve housing stability, improve behavioural health and functioning, and reduce their ED use. Findings showed that HF is effective in stably housing frequent ED users despite their complex health needs.

The Healthcare Triple Aim in the Recovery Era.

Recovery is the guiding vision of mental health systems and policy. However, skepticism has emerged about whether the paradigm can achieve its sought goals. We argue that embedding recovery within a quality improvement framework, such as the Triple Aim, would increase leverage for systems change and advance recovery practice.