Publications by authors named "Emmy Tiderington"

24 Publications

  • Page 1 of 1

Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness.

Med Care 2021 Apr;59(Suppl 2):S199-S205

Center for State Health Policy, Institute for Health, Health Care Policy and Aging Research.

Background: Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations.

Objective: To evaluate the effects of PSH on Medicaid enrollees across New Jersey.

Research Design: Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement.

Subjects: A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014.

Results: PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC).

Conclusions: Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.
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http://dx.doi.org/10.1097/MLR.0000000000001443DOI Listing
April 2021

Negotiating child protection mandates in Housing First for families.

Child Abuse Negl 2021 May 1;115:105014. Epub 2021 Mar 1.

School of Social Work, Rutgers University, The State University of New Jersey, New Brunswick, NJ, USA.

Background: Housing First (HF) is an evidence-based service model that combines permanent housing and supportive case management premised on harm reduction and consumer self-determination to end homelessness for high-need individuals. Originally developed for use with single adults, this model is now being employed with families. Yet there is little empirical work on how HF is implemented with this particular population.

Objective: The aim of this study is to examine how frontline providers adapt and apply HF to formerly homeless or at-risk, families involved in child welfare.

Participants And Setting: Frontline providers working in family HF programs (N = 59) were recruited from two states, across 11 organizations, and 16 program sites. The theoretical sample (n = 26) includes 13 participants working in programs that encouraged direct collaboration with Child Protective Services (CPS) in the program model and 13 participants from three non-CPS-aligned sites in a second state.

Methods: A grounded theory approach was used to analyze semi-structured, qualitative interviews.

Results: Frontline providers exercised street-level bureaucratic discretion when interpreting child protection reporting mandates and they found ways to adapt the HF model to this population. In doing so, they worked to juggle both their mandates to child protection and to principles of HF to create a "child safety-modified" form of HF.

Conclusions: While our study shows that providers are modifying HF to address the needs of families involved in child welfare, it also raises questions as to the degree to which HF can be done with high fidelity when used with this population.
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http://dx.doi.org/10.1016/j.chiabu.2021.105014DOI Listing
May 2021

Moving On From Supportive Housing (MOSH): Development and evaluation of a transitional skill-building curriculum for providers helping residents exit homeless services.

Eval Program Plann 2021 Apr 30;85:101913. Epub 2021 Jan 30.

Rutgers, The State University of New Jersey, School of Social Work, United States.

This article describes the development and evaluation of MOSH (Moving On From Supportive Housing), a transitional skill-building curriculum for providers helping residents exit homeless services to mainstream housing without embedded supports. In this evaluation, we assess the feasibility, acceptability, fit, and potential efficacy of the MOSH curriculum to improve proximal provider-level outcomes, including self-efficacy to provide MOSH-related independent living skills and supports. Homeless-services providers (N = 49) from a range of programs and settings participated in the training. Findings from focus groups and pre- and posttest surveys indicate high levels of overall satisfaction with the training. The majority of trainees perceived the training to be useful to their work and potentially useful for service recipients, felt the training would fit well within their existing day-to-day work, and said they were very likely to use MOSH skills in such work. Statistically significant improvements in self-efficacy regarding all skills but one were also found. MOSH holds promise as an intervention that can enhance provider practice and promotion of independent living skills in homeless services. Although these initial findings on MOSH are encouraging, further research will be needed to evaluate provider knowledge gains and effective use of these skills in practice.
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http://dx.doi.org/10.1016/j.evalprogplan.2021.101913DOI Listing
April 2021

Change in housing environment and residential satisfaction following exit from permanent supportive housing.

J Community Psychol 2021 Mar 14;49(2):305-320. Epub 2020 Oct 14.

School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Moving On initiatives (MOIs) transition stable permanent supportive housing (PSH) residents into mainstream housing without embedded services. While this approach frees up PSH for homeless individuals in need, open questions remain regarding MOI recipients' long-term outcomes. This exploratory study examines how housing environment and residential satisfaction, potential predictors of housing retention, change from PSH to mainstream housing. Subjective assessments of housing and neighborhood quality and residential satisfaction, as well as objective neighborhood-level data, are used to examine housing-related change for New York City MOI recipients. Participants generally moved to less-distressed neighborhoods with lower poverty and crime. Subjective perceptions of some aspects of neighborhood and housing quality also improved post-move. Participants tended to move farther from public transportation but were on average located within one mile of the nearest subway station. Results can be taken as early indicators of the potential benefits of MOIs.
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http://dx.doi.org/10.1002/jcop.22458DOI Listing
March 2021

Community integration when moving on from permanent supportive housing.

J Community Psychol 2020 08 9;48(6):1913-1928. Epub 2020 Jun 9.

Department of Psychiatry, Columbia University, New York, New York.

Aims: This study explored community integration within a Moving On initiative that assisted individuals with the transition from permanent supportive housing (PSH) to more independent housing without service requirements.

Methods: Participants completed baseline interviews while in PSH (n = 90) and, for those who moved on, a follow-up 1-year post-move (n = 45). Bivariate analyses and OLS regression were used to examine community integration outcomes and potential correlates.

Results: For participants who moved on, subjective social quality of life and sense of community were higher post-move, while physical integration decreased, and time spent at home increased. Gender, mastery, and housing quality were associated with community integration post-move.

Conclusion: Moving On did not adversely impact most aspects of community integration, though PSH residents may need more support to facilitate participation in routine activities outside their home post-move. Findings also highlight the importance of supporting mastery given its potential role in community integration.
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http://dx.doi.org/10.1002/jcop.22389DOI Listing
August 2020

Strategies for Sustaining Fidelity: A Multi-state Qualitative Analysis in Housing First Programs.

Adm Policy Ment Health 2021 01;48(1):36-45

Columbia University, 1051 Riverside Drive, New York, NY, 10032, USA.

Little is known about long-term fidelity of evidence-based interventions (EBIs) under changing conditions. This study examines how staff at 'mature' (eight or more years in operation) Housing First (HF) programs strategize to sustain EBI fit in different geographic areas in the Mid-Atlantic/Northeastern United States. Six focus groups (FGs) at three purposively selected HF programs were conducted with separate FGs for case managers and supervisors at each site. FG discussions elicited participants' service approaches and strategies in addressing fidelity amidst ongoing changes affecting each program. Thematic content analysis of FG transcripts was conducted using the five HF fidelity domains (housing choice/structure, separation of housing and services, service philosophy, service array, and program structure) as a priori themes with inductive content analyses conducted on data in each theme. Strategies for rigor were employed. Case managers (N = 17) and supervisors (N = 16) were predominantly white (76%) and female (60%). Across the themes, challenges included lack of affordable housing and choice, funders' restrictions and practice 'drift.' Strategies included community engagement and hiring, strong leadership and 'bending the rules.' There were no differences across sites. Later-stage implementation challenges show the need for continued vigilance in fidelity to EBIs. Among the strategies used to address fidelity in this study, the pursuit of pro-active community engagement to attract knowledgeable staff as well as increase local buy-in was considered pivotal at all three sites. These findings underscore the need to attend to the external setting as well as to internal program operations.
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http://dx.doi.org/10.1007/s10488-020-01041-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7581620PMC
January 2021

"I achieved being an adult": A Qualitative Exploration of Voluntary Transitions from Permanent Supportive Housing.

Authors:
Emmy Tiderington

Adm Policy Ment Health 2021 01;48(1):9-22

Rutgers School of Social Work, The State University of New Jersey, 360 Dr. Martin Luther King Blvd., Hill Hall, Suite 401C, Newark, NJ, 07102-1801, USA.

This study examined how individuals voluntarily leaving permanent supportive housing (PSH) through a Moving On initiative experienced the transition from PSH services to mainstream housing. Participants (N = 25) were purposively sampled from five supportive housing agencies in a Moving On initiative. A modified grounded theory approach was used to analyze semi-structured, post-move interviews. Participants described the transition from PSH as a process that involved gaining freedom from negative aspects of the PSH environment and a stagnation in services, adjusting to a new environment and the loss of familiar supports, taking on new responsibilities of self-advocacy and managing new financial burdens, and feeling empowered to move on to next steps, which ultimately, led to achievement of independence. Various contextual conditions, including PSH- and postmove housing type, influenced participants' experience of this process. Findings can inform future Moving On initiatives, implementation of PSH programs, as well as the design of the larger homeless service system.
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http://dx.doi.org/10.1007/s10488-020-01036-zDOI Listing
January 2021

Stakeholder Perspectives on Implementation Challenges and Strategies for Moving On Initiatives in Permanent Supportive Housing.

J Behav Health Serv Res 2020 07;47(3):346-364

Graduate School of Social Service, Fordham University, New York, USA.

Moving On Initiatives (MOIs) assist individuals with the transition from permanent supportive housing to mainstream housing without the embedded supports. This emerging innovation has the potential to increase behavioral health system capacity and provide recipients with the opportunity to live in the least restrictive setting. However, few empirical studies have examined MOIs, and little is known about the implementation challenges providers face and strategies they use to realize these initiatives in practice. To identify these challenges and strategies, this study utilized over 2 years of observations at MOI "learning collaboratives," as well as eight focus groups with implementation stakeholders. Analyses informed by the Consolidated Framework for Implementation Research (CFIR) identified challenges in the outer and inner service settings, as well as at the individual and innovation level. Outer setting challenges were most prominent in the data, and one non-CFIR construct, macrosystemic characteristics arose inductively. Implications for behavioral health policy and practice are discussed.
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http://dx.doi.org/10.1007/s11414-019-09680-6DOI Listing
July 2020

Medicaid Utilization and Spending among Homeless Adults in New Jersey: Implications for Medicaid-Funded Tenancy Support Services.

Milbank Q 2020 03 22;98(1):106-130. Epub 2020 Jan 22.

Monarch Housing Associates.

Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and reduce avoidable hospital costs for homeless populations. Compared with nonhomeless adult Medicaid beneficiaries, homeless adult beneficiaries have higher levels of health care needs, due in part to mental health issues and substance use disorders. Homeless adults are also more likely to visit the emergency department or require inpatient admissions. Emergency care and inpatient admissions may sometimes be avoided when individuals have high-quality community-based care and healthful living conditions. Offering tenancy support services that help homeless adults achieve stable housing may therefore be a cost-effective strategy for improving the health of this vulnerable population while reducing spending on avoidable health care interventions. Medicaid beneficiaries with disabling health conditions and more extensive histories of homelessness experience the most potentially avoidable health care interventions and spending, with the greatest opportunity to offset the cost of offering tenancy support benefits.

Context: Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending.

Methods: Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries.

Findings: More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups.

Conclusions: A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.
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http://dx.doi.org/10.1111/1468-0009.12446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7077786PMC
March 2020

Employment experiences of formerly homeless adults with serious mental illness in Housing First versus treatment first supportive housing programs.

Psychiatr Rehabil J 2020 Sep 17;43(3):253-260. Epub 2019 Oct 17.

School of Social Service Administration, University of Chicago.

Objective: This paper examines how formerly homeless adults with serious mental illness living in Housing First (HF) and "treatment first" (TF) supportive housing programs experience employment. Research questions include: How do these individuals experience employment in the context of their mental health recovery? What do they perceive as the benefits of and obstacles to attaining employment? Are there programmatic differences in their employment experiences?

Method: Case study analyses of data from a federally funded qualitative study were conducted of 40 individuals purposively sampled from HF and TF programs. Data were independently analyzed and consensually discussed to develop cross-case themes.

Results: Three themes emerged: (a) the meaning of work, (b) working within the system, and (c) balancing treatment requirements and work. While none of the study participants had full-time jobs, more HF program clients had part-time employment than their TF counterparts. Of the 12 employed participants, all but 2 worked within their respective programs. Participants in both groups described similar benefits of obtaining employment, but TF program requirements inhibited job-seeking.

Conclusions And Implications For Practice: These findings provide insight into the challenges of obtaining employment for formerly homeless individuals with serious mental illness residing in supportive housing. Despite the motivation to work, individual, structural, and organizational factors impeded employment. To address this problem, factors at each of these levels will need to be considered. Interventions such as supported employment offer promise to supportive housing programs committed to employment as a contributor to recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/prj0000391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162698PMC
September 2020

Long-term effectiveness of housing and support services for homeless adults with mental illness.

Authors:
Emmy Tiderington

Lancet Psychiatry 2019 11 7;6(11):879-881. Epub 2019 Oct 7.

Rutgers School of Social Work, New Brunswick, NJ 08901, USA. Electronic address:

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http://dx.doi.org/10.1016/S2215-0366(19)30372-4DOI Listing
November 2019

"How do we force six visits on a consumer?": Street-level dilemmas and strategies for person-centered care under Medicaid fee-for-service.

Am J Psychiatr Rehabil 2018 Spring-Summer;21(1-2):79-101

New York University, Silver School of Social Work.

This qualitative study examines the delivery of person-centered care in Medicaid-funded supportive housing for adults with serious mental illness. While much work has been done to promote the uptake of a person-centered approach in healthcare, less is known about how this approach functions in homeless services and supportive housing where many individuals with mental health issues receive rehabilitative services. A total of 84 semi-structured interviews were collected from a purposeful sample of 35 frontline providers. Transcripts were analyzed inductively using Boytazis' thematic analysis. Three principle themes characterize the dilemmas experienced by street-level workers in these programs: (1) Putting the "consumer first" vs. achieving maximum billing; (2) Doing the "real work" vs. paperwork; and (3) Juggling clinical supervision vs. administrative oversight. In order to meet the demands of Medicaid, as well as the expectation for person-centered care delivery, providers enacted several discretionary strategies at the street-level: (1) Staying late and taking work home; (2) Padding the numbers; (3) Offering service recipients small choices; (4) Redirecting small talk to get to billable goal talk; and (5) Keeping consumers home. Findings highlight tensions between the accountability-focused fee-for-service model and the prioritization of consumer choice and individualization of services in person-centered care delivery.
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http://dx.doi.org/10.7282/t3-abqz-4q92DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812544PMC
October 2019

Sorting it out: Eliciting consumer priorities for recovery in supportive housing.

Am J Psychiatr Rehabil 2016 19;19(3):223-234. Epub 2016 Aug 19.

New York University, New York, United States.

Objective: This study aims to understand participant priorities in their personal recovery journey and their perspectives of recovery domains.

Methods: A card sort data gathering technique was employed to elicit priorities in recovery from consumers in supportive housing programs serving formerly homeless adults with severe mental illnesses in New York City. Participants (N=38) were asked to sort 12 cards printed with recovery domains in order of importance and describe the meaning attached to each domain.

Results: Mental health (95%), physical health (89%), and housing (92%) were the domains most frequently included and prioritized in the top three rankings. Family (76%) and partner (74%) were also frequently included and endorsed as most important second only to mental health. Housing was prioritized yet rated most important less often (58%). Work, school, hobbies, program, friends and neighborhood were less frequently endorsed. 'Card sort talk' revealed critical understanding of participants' priorities and their reasons for endorsing other domains less frequently.

Conclusions: Most important to participants was regaining functional independence through improved mental and physical health and access to housing. With underlying principles of efficiency and empowerment, card sort is a promising engagement technique for providers to elicit consumer priorities in their own recovery.
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http://dx.doi.org/10.1080/15487768.2016.1197862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321566PMC
August 2016

Case Manager Perspectives on the Role of Treatment in Supportive Housing for People with Severe Mental Illness.

J Soc Social Work Res 2016 19;7(3):507-525. Epub 2016 Jul 19.

New York University.

Objective: Growing recognition exists of housing as a social determinant of health, and thus, health care reform initiatives are expanding the reach of health care beyond traditional settings. One result of this expansion is increased Medicaid funds for supportive-housing programs for people with severe mental illnesses. This qualitative study explores the ways in which case managers working in a supportive housing program approach treatment and how their approach is influenced by both program requirements and their beliefs about mental illness.

Method: The study is part of a longitudinal qualitative study on recovery for people with severe mental illnesses living in supportive housing. Multiple interviews ( = 55) with 24 case managers from a residential-continuum supportive-housing program were conducted over 18 months. To provide an in-depth view of case manager perspectives, the study uses thematic analysis with multiple coders.

Results: Overall, case managers understand supportive housing as being a treatment program but predominantly characterize treatment as medication management. The following themes emerged: believing medication to be the key to success in the program, persuading residents to take medication, and questioning the utility of the program for residents who were not medication adherent.

Conclusions: Case managers understand supportive housing to be a treatment program; however, given the external constraints and their own beliefs about mental illness, case managers often equate treatment with taking medication. Study findings demonstrate the need to train case managers about mental health recovery and integrated health care. The findings also have implications for policies that tie housing to services.
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http://dx.doi.org/10.1086/687986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289652PMC
July 2016

"The Apartment is for You, It's Not for Anyone Else": Managing Social Recovery and Risk on the Frontlines of Single-Adult Supportive Housing.

Authors:
Emmy Tiderington

Adm Policy Ment Health 2018 01;45(1):152-162

School of Social Work, Rutgers, The State University of New Jersey, 360 Dr. Martin Luther King Blvd., Hill Hall, Suite 401A, Newark, NJ, 07102-1801, USA.

This multi-method qualitative study examines frontline provider perspectives on consumer social relationships and barriers to social recovery in supportive housing programs for adults with serious mental illness. Thematic analyses show that guest and occupancy policies that enforce the "single" nature of single-adult supportive housing challenge consumer rights to self-determination in the realm of social recovery. Findings also highlight the ways in which providers act to reinforce and subvert these policies while mitigating risk in this service setting. Recommendations for enhancing the recovery orientation of supportive housing and implications for the design of the homeless service system are discussed.
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http://dx.doi.org/10.1007/s10488-016-0780-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450384PMC
January 2018

Trajectories of Recovery Among Formerly Homeless Adults With Serious Mental Illness.

Psychiatr Serv 2016 06 14;67(6):610-4. Epub 2016 Feb 14.

Dr. Padgett, Ms. Choy-Brown, and Dr. Mercado are with the Silver School of Social Work, New York University, New York City (e-mail: ). Ms. Smith is with the School of Social Service Administration, University of Chicago, Chicago, Illinois. Dr. Tiderington is with the School of Social Work, Rutgers University, New Brunswick, New Jersey.

Objective: Recovery from mental illness is possible, but individuals with co-occurring disorders and homelessness face challenges. Although a nonlinear recovery course is assumed, few studies have analyzed recovery over time. This mixed-methods study examined recovery trajectories over 18 months after enrollment in supportive housing programs of 38 participants with DSM axis I diagnoses.

Methods: Qualitative interview data were quantified through consensual ratings to generate a recovery score for four waves of data collection based on eight recovery domains culled from the literature. Case study analyses were conducted of participants whose scores varied by one standard deviation or more between baseline and 18 months to identify which domains were important.

Results: Most of the 38 participants (N=23) had no significant change in recovery; seven had a negative trajectory, and eight had a positive trajectory. Case studies of these 15 participants indicated domains that contributed to change: significant-other relationships (N=9), engagement in meaningful activities (N=9), mental health (N=7), family relationships (N=6), general medical health (N=5), housing satisfaction (N=5), employment (N=2), and substance use (N=1). Except for mental health and substance use (which contributed only to negative trajectories), the influence of domains was both positive and negative. Domains were intertwined; for example, variation in relationships was linked to changes in meaningful activities.

Conclusions: This study showed little change in recovery over time for most participants and a decline in mental health for a small minority. Findings underscore the importance of social relationships and meaningful activities among individuals with serious mental illness, who experience complex challenges.
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http://dx.doi.org/10.1176/appi.ps.201500126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4915343PMC
June 2016

Complex Recovery: Understanding the Lives of Formerly Homeless Adults with Complex Needs.

J Soc Distress Homeless 2016 26;25(2):60-70. Epub 2016 Jul 26.

School of Social Work, University of Southern California, 1150 S. Olive St. Rm. T320, Los Angeles, CA 90015 USA;

Objective: This report examines mental health recovery in a population neglected in the literature--formerly homeless adults with serious mental illness and co-occurring substance abuse. The term 'complex recovery' is used to examine the onset and impact of various types of adversity over the life course.

Method: Burawoy's extended case method was conducted on in-depth interviews with 74 formerly homeless adults living in housing programs in New York City. Data included verbatim transcripts, interviewer feedback forms, and case summaries.

Results: Seven themes emerged: the longstanding influence of poverty, childhood hardship, social support and network depletion, substance abuse and recovery, unequal impact of gender differences, experiences of incarceration and fragmented service system. Structural as well as individual factors were found to comprise complex recovery.

Conclusions: Complex recovery, which situates mental health recovery amidst homelessness and other forms of adversity, has implications for policies and practices designed to assist this vulnerable population.
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http://dx.doi.org/10.1080/10530789.2016.1173817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400368PMC
July 2016

"We Always Think You're Here Permanently": The Paradox of "Permanent" Housing and Other Barriers to Recovery-Oriented Practice in Supportive Housing Services.

Authors:
Emmy Tiderington

Adm Policy Ment Health 2017 Jan;44(1):103-114

Rutgers School of Social Work, Rutgers, The State University of New Jersey, 360 Dr. Martin Luther King Blvd., Hill Hall, Suite 401A, Newark, NJ, 07102-1801, USA.

This qualitative study examines the views and practices of frontline providers working in supportive housing for adults with serious mental illness and how frontline workers understand their work as it relates to consumer mental health recovery. Utilizing 84 interviews with providers (N = 35) and 106 hours of observation of provider practice, a grounded theory of frontline practice in supportive housing is provided. Analyses revealed distinct differences between providers working within transitional versus permanent housing programs in their orientation to recovery. Implications for the design of the supportive housing continuum of care are discussed.
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http://dx.doi.org/10.1007/s10488-015-0707-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907886PMC
January 2017

Unpacking Clinical Supervision in Transitional and Permanent Supportive Housing: Scrutiny or Support?

Adm Policy Ment Health 2016 07;43(4):546-54

Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003-6654, USA.

Behavioral health organizations use clinical supervision to ensure professional development and practice quality. This qualitative study examined 35 service coordinators' perspectives on supervision in two distinct supportive housing program types (permanent and transitional). Thematic analysis of in-depth interviews yielded three contrast themes: support versus scrutiny, planned versus impromptu time, and housing first versus treatment first. Supervisory content and format resulted in differential perceptions of supervision, thereby influencing opportunities for learning. These findings suggest that unpacking discrete elements of supervision enactment in usual care settings can inform implementation of recovery-oriented practice.
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http://dx.doi.org/10.1007/s10488-015-0665-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676950PMC
July 2016

A picture is worth . . . ? Photo elicitation interviewing with formerly homeless adults.

Qual Health Res 2013 Nov 11;23(11):1435-44. Epub 2013 Oct 11.

1New York University, New York, New York, USA.

We report on the use of photo elicitation interviewing (PEI) with 13 participants in a qualitative study of formerly homeless men and women with serious mental illness. Following a respondent-controlled approach, participants were asked to take up to 18 photographs visually portraying positive and negative aspects of their lives and to subsequently narrate the meaning of the photos in a one-on-one interview. Thematic analysis of the photos (N = 205) revealed two approaches to PEI: (a) a "slice of life" and (b) "then vs. now." Examples show how PEIs yielded deeper, more elaborate accounts of participants' lives compared to earlier verbal-only interviews. Participants spoke of the benefits of PEI and preferred taking positive as opposed to negative photographs depicting their lives. Implications of PEI as a means of complementing verbal-only data are discussed. By moving away from predetermined content and meaning, respondent-controlled PEIs enhance empowerment and enable creativity.
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http://dx.doi.org/10.1177/1049732313507752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992880PMC
November 2013

Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults.

J Behav Health Serv Res 2014 Jan;41(1):80-9

School of Social Work, University of Southern California, 1150 S. Olive Street, T320, Los Angeles, CA, 90015, USA,

Harm reduction is considered by many to be a legitimate alternative to abstinence-based services for dually diagnosed individuals, yet there is limited understanding of how varying approaches affect front-line practice within services for homeless adults. This paper examines how front-line providers working with individuals who have experienced homelessness, serious mental illness, and addiction view policies of harm reduction versus abstinence within two different approaches to homeless services: the traditional or "treatment first" approach that requires abstinence, and the more recent housing first approach that incorporates harm reduction. As part of a federally funded qualitative study, 129 in-depth interviews conducted with 41 providers were thematically analyzed to understand how providers view harm reduction versus abstinence approaches. Themes included the following: (a) harm reduction as a welcomed alternative, (b) working with ambiguity, and (c) accommodating abstinence. Drawing on recovery principles, the authors consider the broader implications of the findings for behavioral health care with this population.
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http://dx.doi.org/10.1007/s11414-013-9318-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675178PMC
January 2014

Substance Abuse Recovery after Experiencing Homelessness and Mental Illness: Case Studies of Change Over Time.

J Dual Diagn 2012 Jan 8;8(3):238-246. Epub 2012 Aug 8.

Silver School of Social Work, 838 Broadway, 3 Floor, New York Recovery Study, New York, NY 10003, Ph: 212-992-9733.

OBJECTIVE: This paper addresses how consumers with dual diagnosis, who were formerly homeless but are now living in supportive housing, understand their recovery from substance abuse (i.e., substance abuse or dependence). Specifically, this study examined: What can be learned about substance abuse recovery from consumers considered to be doing well; how past substance abuse fits into their present-day narratives; and how (if at all) policies of harm reduction versus abstinence are regarded as affecting recovery efforts. METHODS: As part of a federally-funded qualitative study, 38 individuals who met criteria for having achieved a measure of success in mental health recovery were purposively sampled from two supportive housing agencies - one using a harm reduction and the other an abstinence model. Researchers conducted in-depth interviews and used case study analysis, the latter including the development of case summaries and data matrices, to focus on substance abuse recovery in the larger context of participants' lives. RESULTS: Recovery from substance abuse was depicted as occurring either through discrete decisions or gradual processes; achieving recovery was distinct from maintaining recovery. Emergent themes related to achievement included: (a) pivotal events and people (b) maturation, and (c) institutionalization. Central themes to maintaining recovery were: (a) housing, (b) self-help, and (c) the influence of significant others. CONCLUSIONS: These findings capture a complex picture of overcoming substance abuse that largely took place outside of formal treatment and was heavily dependent on broader contexts. Equally important is that consumers themselves did not necessarily view substance abuse recovery as a defining feature of their life story. Indeed, recovery from substance abuse was seen as overcoming one adversity among many others during their troubled life courses.
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http://dx.doi.org/10.1080/15504263.2012.697448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3433069PMC
January 2012

Life course adversity in the lives of formerly homeless persons with serious mental illness: context and meaning.

Am J Orthopsychiatry 2012 Jul;82(3):421-30

Silver School of Social Work, New York University, 1 Washington Square North, Room 416, New York, NY 10003, USA.

This qualitative study assessed the frequency and subjective meaning of adverse experiences using case study analyses of interviews with 38 formerly homeless adults with co-occurring serious mental illness (SMI) and substance abuse histories. Adverse life events were inventoried using an adaptation of Lloyd and Turner's (2008) 41-item checklist. Participants averaged 8.8 adverse events, with approximately one-third having experienced incarceration (37%), suicidality (32%), abandonment by one or both parents (30%), and death of their mother (34%). Cross-case analyses yielded 3 themes: social losses because of death and estrangement; the significance of chronic stressors as well as acute events; and the cumulative lifetime nature of adversity. Findings suggest that life course experiences of trauma and loss have a cumulative influence in the lives of this population in addition and in relation to SMI, substance abuse, and homelessness. In this context, the mental health recovery movement should address prior adverse experiences beyond comorbid diagnoses in this population.
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http://dx.doi.org/10.1111/j.1939-0025.2012.01159.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3422756PMC
July 2012

A qualitative analysis of case managers' use of harm reduction in practice.

J Subst Abuse Treat 2013 Jan 19;44(1):71-7. Epub 2012 Apr 19.

New York University, Silver School of Social Work, New York, NY 10003-6654, USA.

The harm reduction approach has become a viable framework within the field of addictions, yet there is limited understanding about how this approach is implemented in practice. For people who are homeless and have co-occurring psychiatric and substance use disorders, the Housing First model has shown promising results in employing such an approach. This qualitative study utilizes ethnographic methods to explore case managers' use of harm reduction within Housing First with a specific focus on the consumer-provider relationship. Analysis of observational data and in-depth interviews with providers and consumers revealed how communication between the two regarding the consumer's substance use interacted with the consumer-provider relationship. From these findings emerged a heuristic model of harm reduction practice that highlighted the profound influence of relationship quality on the paths of communication regarding substance use. This study provides valuable insight into how harm reduction is implemented in clinical practice that ultimately has public health implications in terms of more effectively addressing high rates of addiction that contribute to homelessness and health disparities.
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http://dx.doi.org/10.1016/j.jsat.2012.03.007DOI Listing
January 2013