Perspectives on a transitional housing program for people who use substances who experience homelessness and live with a mental health issue: a pilot study in an urban northern city in Canada

Abstract

Background

A new transitional housing program was established in Sudbury, Ontario, Canada, in response to the escalating prevalence of substance use and homelessness, and the specific challenges faced in Northern Ontario. There is a scarcity of research investigating the implementation of housing programs with clinical, social, and functional support for people with substance use in Northern settings in the era of Fentanyl and its analogs and a contaminated dangerous drug supply. To bridge this knowledge gap, we evaluated a unique harm reduction-focused transitional housing program. Our study objectives encompassed exploring patients’ viewpoints on considerations when implementing a transitional housing program for people with substance use and mental disorders.

Methods

This is a qualitative interview study of 12 clients from a transitional housing program that offers comprehensive health and social assistance through addiction medicine, psychiatric consultation, primary care, and harm reduction services to clients in a transitional housing program in an Urban setting in Northern Canada. This study was a pilot project, to gather their perspectives on the care provided by the team. Maslow’s Hierarchy of Needs was used to contextualize the data.

Results

Participants emphasized the importance of the program’s housing first approach, its positive impact on accessing health and social services, and the increase in sense of belonging, self-esteem, and confidence because of being in the program. Participants also indicated that the program had a positive overall impact, leading to reduced substance use, improved mental and emotional well-being, and enhanced socio-economic conditions. However, several considerations were highlighted as important for ensuring the effectiveness of the program, such as better aligning client and program expectations, facilitating access to community supports with food, support with medication regimen, providing empathetic engagement, and individualizing approaches to care.

Conclusion

A new transitional housing program in a Northern Urban setting in the era of an increasingly contaminated drug supply led to perceived positive outcomes for clients. Important considerations include focusing (or enhancing supports) on physiological needs and empathetic, individualized approaches to care.

Introduction

Homelessness poses complex societal challenges that impact health and well-being. Those experiencing homelessness face elevated rates of substance use disorders, mental health issues, infectious diseases, cardiovascular and metabolic problems, and cognitive impairments [8, 11]. Unfortunately, this demographic also experiences a significantly higher risk of premature mortality compared to the general population, with substance use-related factors playing a substantial role in these elevated mortality rates [1, 23].

People who experience homelessness accounted for 1in 6 opioid-overdose deaths in 2021 and homelessness has been on the rise in municipalities across Canada [5]; the rise is much more rapid in Northern Ontario [5]. Between 2016 and 2023, Canada saw over 40,000 deaths attributed to opioids, with Ontario contributing 25% of those deaths—10,900 fatalities [20]. Northern Ontario, which accounts for under 10% of the population, saw approximately 15% (1,411) of the deaths during this period [19].

Addressing homelessness can positively influence health outcomes [9]. However, traditional housing approaches often require prerequisites like abstaining from substance use or adhering to psychiatric medications as part of a “treatment first” housing model [25, 29]. These requirements inadvertently worsen the social exclusion experienced by many individuals grappling with mental health or substance use disorders while homeless.

In contrast, the “housing first” approach prioritizes addressing the primary needs of people experiencing homelessness without mandating sobriety or treatment adherence, which helps reduce prolonged homelessness and housing instability [21]. Despite its benefits, there remains insufficient research on the ongoing importance of integrating harm reduction principles in housing support strategies, creating a gap between research evidence and practical implementation that hinders patient-centered care [28].

In January 2022, Health Sciences North (HSN) and the City of Greater Sudbury launched a transitional housing program designed to meet the complex needs of individuals experiencing homelessness and facing mental health and substance use challenges. In Northern Ontario, homelessness and substance use are compounded by vast geography, and limited resources [4]. Many areas face a lack of shelters, housing, and addiction services [7], and economic challenges, like high unemployment, further exacerbate the issues [3]. Addressing these challenges requires innovative, collaborative, and culturally relevant solutions. Based on the Housing First Philosophy [21] while employing harm reduction strategies, the program provides immediate access to transitional housing within a supportive environment much like other housing first programs. Although the program was initially rooted in the Housing First approach, it has distinct features. It includes integrated clinical and social supports on-site and is designed as a transitional program aimed at helping clients build the skills needed to move into permanent housing. However, there are aspects of the program, particularly early on, where clients have less autonomy compared to other Housing First programs.

This approach aims to enhance well-being and prepare residents for independent living by offering specialized care and skill-building tailored to individuals at varying stages of stability in substance use. The program’s comprehensive model addresses both medical and psychosocial needs through a dedicated team of professionals, including nurses, addiction workers, social workers, primary care physicians, and psychiatrists, who collaborate to enhance clients’ skills and abilities for sustained, independent housing.

The program’s effectiveness hinges on its ability to improve health and social outcomes and integrate seamlessly into the healthcare and social support system, while prioritising stable housing. With this in mind, our research adds to the evidence base for the integration of harm reduction principles within supportive housing strategies through exploring patients ‘ experiences within this unique transitional housing program. Therefore, our objective was to explore patients’ experiences within this unique transitional housing program.

Methods

Design, setting and program overview

This is a qualitative interview study of 12 clients from a transitional housing program that offers comprehensive health and social assistance through addiction medicine, psychiatric consultation, primary care, and harm reduction services to clients in a transitional housing program in an Urban setting in Northern Canada. This study was a pilot project, to gather their perspectives on the care provided by the team. Maslow’s Hierarchy of Needs was used to contextualize the data.

Functioning as a vital component of community mental health and addiction care in an urban city in Northern Ontario, the transitional housing program integrates support services focused on fostering independent living skills. Each client has a private room and bathroom and share a congregate kitchen. The program’s scope encompasses healthcare, substance use care, mental health consultation, and broader social support.

Admission to the program follows a referral process via Ontario’s by-names list, with eligibility determined by a high vulnerability score using the Vulnerability Index—Service Prioritization Decision Assistance Tool (VI-SPDAT) assessment [6]. Prospective clients undergo an initial program interview to ascertain suitability. The program is inclusive, accepting individuals whether they are actively using substances or not. Once admitted, clients receive transitional housing for up to 18 months, aimed at fostering wellness and enhancing skills necessary for stable housing. The program actively supports clients in overcoming personal barriers, providing tools to access essential services such as local food banks, dental and psychiatric appointments, addiction treatment, legal support, vocational training, and more, thereby facilitating their path toward stable housing.

Aligned with the organization’s harm reduction philosophy [14], the transitional housing program emphasizes specialized care tailored to individuals at varying stages of stability in substance use. This holistic approach addresses both medical and psychosocial needs, delivering comprehensive wrap-around care through a multidisciplinary team of professionals including nurses, addiction specialists, social workers, primary care physicians, and psychiatrists. Together, this collaborative team endeavors to enhance clients’ capabilities and empower them toward achieving sustained, independent housing.

Population

The inclusion criteria for the program are as follows: individuals must be chronically homeless (for a minimum of six months) and interested in obtaining permanent housing, be 16 years of age or older, and able to complete activities of daily living and ambulate independently. They must be listed on the City of Greater Sudbury’s By Name list and identified as tri-morbid (experiencing physical, mental health, and addiction challenges), with a Vulnerability Index score of 14 or above for CGS admission or 8 or above for HSN admission. Additionally, they must be motivated to engage with the healthcare team and meet the specific building and housing criteria. Exclusion criteria include individuals who require 24-h support or monitoring, have pets or dependents, or have a criminal record that prevents interaction with minors. A special circumstance applies to clients who are part of a case management team that will discharge them from the program if admitted to the Lotus Program, following a case conference.

Theoretical underpinning

Maslow’s Hierarchy of Needs [17] was used to contextualize the data. It is a foundational theory in human motivation [17], frequently applied in strategies like housing-first and community-based interventions for supporting individuals experiencing homelessness. The theory posits that people are driven to fulfill unmet needs, prioritizing the most basic ones first. At the base of the hierarchy are physiological needs such as health, food, sleep, and shelter—fundamental necessities for survival. Moving up, safety needs involve protection from harm, ill health, stability, and secure employment or housing. Next, the need for belonging which encompasses social connections, love, and being part of a community or family, followed by esteem needs which include self-respect, recognition, and status. Self-actualization represents the pinnacle—where individuals strive to achieve their full potential and personal growth. This hierarchical framework guides interventions by addressing these needs in sequence, aiming to support individuals in overcoming challenges and achieving stability and fulfillment in their lives [17].

Procedures

The current study is part of a broader mixed-method evaluation of the transitional housing program [18]. The results presented in this manuscript represent a pilot project. The focus is on qualitative interviews conducted with clients who were housed within the program, aiming to understand their experiences with the program and to obtain their feedback on how the program can be improved.

From June to August 2023, semi-structured interviews were conducted with 12 clients. All clients in the program had the opportunity to participate in the study, presented by the program or research staff. Research staff (including a peer researcher and the principal investigator) were available weekly to recruit participants. Interested clients could proceed with immediate interviews or schedule later sessions. The research staff obtained the patient’s consent and conducted interviews in person utilizing key questions developed in consultation with a person with living experience with homelessness and substance use.

Compensation included $20 cash. Interviews were audio-recorded, transcribed, and stored securely. Practical considerations, such as the availability of participants within the specified timeframe and the resources required for data collection and analysis, were taken into account. Results were shared with the program staff and hospital for quality improvement purposes, in addition to scientific publication.

The interview transcripts were structured using in a spreadsheet and subjected to a deductive thematic analysis [2]. Themes were identified through manual analysis, without the use of any software. This approach involved several steps: first, transcribing the interviews, reading the transcripts, and creating notes; second, conducting a second reading to identify concepts present and code them; and next, developing and refining an initial list of codes. These codes were then organized into primary groupings, and coded excerpts were reviewed to ensure their alignment with these groupings. This iterative process allowed for further refinement and the identification of overarching themes related to the groupings and underlying subthemes from the concepts.

Several fundamental approaches were implemented to maintain the quality of the research. The study questions were developed, and the interviews were conducted with people who use substances. We established an audit trail, collaboratively coding transcript subsets with the peer researcher on our team who conducted the interviews), and holding frequent meetings to assess coding and ensure the reliability of the analysis.

Results

Approximately 35% of the clients in the program are female, the average age is approximately 30 years old, approximately 50% identify as indigenous and clients report being unhoused for an average of 10 months in the last year. Specific demographics of those who took part in this study have not been provided to maintain confidentiality.

Participants identified several key factors that are important to consider in this type of program encompassing various dimensions of their well-being based on Maslow’s hierarchy of needs [17].

Physiological needs

Participants highlighted the critical importance of having their basic needs met, particularly stable accommodation. One participant expressed, P10″I just like the stability of knowing where you’re sleeping.” Another emphasized, P11 “Just having a place to stay is huge. Just having a place to sleep and shelter overnight.” These sentiments underscored how secure housing provided a foundation of stability and security in their lives. Participants also expressed gratitude for having a roof over their heads, with one stating, P4″So that’s why I like having a roof over my head. It makes me go forwards, it makes me be better and feel more comfortable and getting my stuff done.”

Food security emerged as a very important factor in being able to participate in the program. Many expressed difficulties in meeting their nutritional needs due to personal financial constraints. One participant shared,P6 “And the food thing man. It’s so hard making it on your own. Like 300 bucks is not enough for food… It’s hard to get enough food to survive." Another participant added, P3 “On the street it was easier to get food, we were part of the like homeless network like, [local organization] would help out more and the shelters and that. Now I’m cut off from that so ugh I basically go to the foodbank and … [local organization] still helps…”.

Safety and security

Access to medication emerged as a significant factor contributing to positive experiences and feeling safe and stable. Participants appreciated the convenience and support in managing their medication within the program setting. One participant noted, P2 “Well for me it’s good to have, for me not to have to go downtown to get my drink. I like that I don’t have to go downtown, and I do my samples here too.” Another highlighted how being in the program facilitated better adherence to their medication regimen, stating, P9 “Seems to help with […] keeping up with medication, I guess. When I was out there I wasn’t taking my medication.”

Safety and security were identified as important foundational needs and difficult to establish within the program while also respecting autonomy and observing harm reduction. Many individuals who are homeless resort to survival behaviours out of necessity, and it often takes time after transitioning to housing for them to unlearn these routines and coping mechanisms developed while living on the streets. One participant voiced frustration, stating, P5 “There’s so much theft going on it’s unbelievable. I get ripped off every […] month.” Despite these challenges, participants also discussed opportunities for personal growth and improvement. They expressed a desire to overcome these obstacles and build a more secure and stable life. Some participants mentioned their efforts to enhance their personal security measures and collaborate with program staff to address safety concerns effectively. With this, there is an opportunity for staff to work with clients to understand what safety looked like, and what rules were reasonable and enforceable to balance restrictions in personal freedom/autonomy with safety and security—transitioning from individual survival to collective community living.

Love and Belonging

The sense of community within the program was highly valued by participants. They described feeling accepted and supported by both staff and fellow clients, likening the environment to a supportive family. One participant reflected, P7 “And I feel very much accepted here, not only by the staff, but the clients as well. It’s very much a little family.”

Participants voiced the importance of inclusive, client-centred policies around visitation from family and social supports. One participant stated, P4″Allowing your family to visit, to come see you and check the place out, they can’t come outside, but it would be nice to show them my room.” This sentiment reflected a desire for greater connection with loved ones and the ability to share their living environment, enhancing familial bonds and emotional support. Participants acknowledged the importance of rules for maintaining order but advocated for more leniency, particularly concerning visitation. One participant commented, P2″I would keep [the rules] very similar to what they are, they’re not hard rules to follow except for the visitors and family stuff.” This perspective highlighted a willingness to adhere to program guidelines while emphasizing the need for adjustments that could positively impact their social interactions and emotional well-being. The visitation policy also affected participants’ social lives and support networks. One participant expressed frustration, saying, “I don’t like the no visiting thing. I have friends and sometimes I want them to come over and they can’t.”

Esteem

Building independence and self-worth were important aspects for participants. Many expressed pride in their achievements within the program, such as obtaining identification, improving personal appearance, and pursuing educational opportunities. One participant shared, P6 “Knowing that I am doing something with my life. I’m involved with [name of organization], and it makes me proud. I’m capable and this is the time.” Supportive staff also played a crucial role in enhancing participants’ self-esteem by providing practical assistance and emotional support.

Participants in the program also expressed the importance of ensuring equitable treatment among residents, advocating for opportunities to decompress upon entry into the program to adapt to their new living situation after having experienced homelessness chronically.

Lastly, participants reported how being in the program, having stable housing and living in a supportive environment contributed to reduced drug use.

Self-actualization

Participants expressed aspirations for personal growth and a better future. They discussed their desires for further education and career development, indicating a strong motivation to improve their circumstances. One participant mentioned, P11 “You know, maybe even going back and doing more education,” highlighting their ambition to pursue new opportunities beyond their current situation.

Participants also voiced a need to be recognized for their efforts and achievements beyond substance use. One participant emphasized, P5 “If you use dope we just have to let them know, like, hey, where you think like that’s how much. But like when you talk to the doctor, it’s like, well, there’s [an] improvement. I am improving. You don’t see it. How much work we’re doing? You don’t see improvement that I’m doing. All you want [is] to take [them] off [their] drugs.” Another said P9 “Even though we’re not meeting the requirements of quitting drugs you know, at least we’re – I’ve changed because of this program; Rethinking who I am and how I treat other people.” This statement reflected a desire for acknowledgment of personal growth and efforts in areas such as mental health, relationships, or personal development, beyond the focus on substance use alone.

Discussion

The findings from this study underscore the critical value of a transitional housing program with integrated clinical supports and a harm reduction philosophy with a core focus on targeting interventions and supports addressing physiological needs, safety and security, love and belonging, esteem, and self-actualization among individuals experiencing homelessness.

Participants consistently emphasized the necessity of stable accommodation and food security. Stable housing provided a sense of stability and security, allowing individuals to focus on personal growth and well-being. Other papers and studies echo similar findings regarding the importance of stable accommodation [16, 24]. Having a stable place to live provides a foundation for individuals to address other challenges, such as mental health issues and substance use disorders. The challenges, even when in the program, related to food security highlighted the ongoing struggle to meet basic nutritional needs. Despite the transition from street life to housing, some participants expressed difficulty in adjusting to new routines and accessing essential resources like food banks. Transitional programs should recognize the multifaceted needs of participants and provide wrap-around services to facilitate successful transitions and long-term stability [21].

Safety emerged as an important factor in the program for participants. Having medication, particularly opioid agonist treatment onsite provided a sense of security due to having barrier-free access to their medication. Many also highlighted the importance of security due to experiences with theft that persisted despite being housed. While transitional housing offered a more secure environment, participants articulated the need for continued support in addressing safety concerns and adapting to new living conditions. Efforts to enhance personal security measures and collaboration with program staff were seen as crucial steps toward fostering a safer living environment. This is consistent with the research indicating that safety concerns, including theft and personal security, are prevalent among individuals experiencing homelessness and persist in transitional housing [15]. Participants often report feeling vulnerable due to past experiences and the challenges of adapting to new, more stable living conditions [27]. Studies highlight the importance of inclusive decision-making processes and active participation of residents in shaping safety policies and practices within housing programs [22]. Consistency in routines and staff relationships can contribute to reducing the sense of vulnerability.

The sense of community within the transitional housing program was valued highly by participants, who described feeling accepted and supported by both staff and peers. Family support and visitation from family and friends was also highly valued. Studies consistently show that a sense of community and belonging contributes positively to the emotional well-being and social integration of individuals in transitional housing [26]. Other studies have also shown that restrictions on visitation policies often pose challenges for residents in maintaining connections with family and friends. Research suggests that flexible guidelines that accommodate social relationships can improve residents’ well-being and support networks [10]. Participants may experience feelings of isolation or strained relationships when visitation policies are overly restrictive, highlighting the need for policies that balance safety concerns with residents’ social and emotional needs.

Participants often express pride in achieving milestones such as obtaining identification or pursuing educational opportunities while in transitional housing. These findings are consistent with other studies and signify progress towards stability and independence, contributing to improved self-esteem and a positive sense of self-worth among participants [12]. It has also been shown that transitional housing programs that foster opportunities for skill development and goal-setting contribute to residents’ sense of hope and agency in shaping their futures [13].

The study has several strengths and limitations. One of the main strengths is its timely focus on a critical research gap regarding transitional housing for individuals with substance use and mental health disorders in Northern Canada, especially given the current drug crisis. The use of semi-structured interviews with 12 clients provides valuable qualitative insights, and the application of Maslow’s Hierarchy of Needs offers a structured approach to understanding the program’s impact on participants. The study also highlights positive outcomes, such as reduced substance use, improved mental health, and better socio-economic conditions. The study also lacks long-term follow-up data, making it difficult to assess the sustainability of the positive outcomes. Additionally, the study does not include comparisons with similar programs in different regions, which could limit the generalizability of its findings. Furthermore, the study does not explore the challenges of implementing the program in different settings, which could affect its replication in other Northern or rural areas.

Implications

This research has led to many policies revised in partnership with the clients to improve the program including revising the visitor policy, enhancing food availability and revising client milestones. The program has also been approved to expand to a 40-unit building, which will enhance its capacity to support clients. Key areas of focus include enhancing nurse and allied health. Additionally, the case management model continues to develop as the client caseload increases, with finalization of discharge pathways and a post-discharge 6-month case management model. Efforts are being made to enhance withdrawal protocols in preparation for the program’s expansion. The research team is working to connect additional data sourses to evaluate quantitative outcomes [18]. One aspect that did not emerge from the client interviews was the harm reduction philosophy underlying the program, which allows clients to continue using substances without facing penalties. Future research should examine the benefits and challenges of this approach and its impact on client outcomes.

Conclusion

In conclusion, the findings underscore the complex interplay of needs and aspirations among individuals transitioning from homelessness to transitional housing. Addressing these multifaceted needs requires a holistic evidence-based approach that integrates empathetic, client-centred supportive services, respects personal autonomy, and fosters a sense of community and belonging. By aligning the individual care plan with Maslow’s needs ensuring the client’s most basic needs are met before pursuing other goals is important to create a framework for more empathetic and organized care plans. By recognizing and addressing these dimensions, transitional housing programs can effectively support individuals in achieving stability, resilience, and personal growth as they navigate the path toward sustained independence and well-being.