Home Again: Housing with Supportive Services for Women with Mental Illness experiencing Long Term Care Needs

Innovation summary

This is a research project to determine whether a housing intervention with supportive services for homeless women with mental disorders experiencing long term care needs results in better outcomes, than care as usual in an institutional setting, in the domains of:

community functioning;
psychological health;
quality of life;
social mobility; and develop a sustainable and cost effective pathway for rehabilitation of people living in institutional spaces.

Impact summary

50 women live in 11 homes
92% demonstrate gains in community functioning over a 6 month period as indicated by the Community Integration Questionnaire (CIQ)

Now I feel like how I did in my younger years, before I became ill, at home, going to school, coming back home, cooking...I feel very delighted...This is good, everyone will be happy, they will feel peaceful that they are at home.

-P, a Home Again service user

Innovation details

The innovation offers shared housing in scattered neighbourhoods with supportive services facilitated by an on site lay worker trained and supervised by a multi disciplinary project team. Components include:

an environment of "home" with a mix of fun, leisure, relationships, spontaneity, participation, shared workload, conflicts, and resolution
co-planning and facilitation of living experiences with personal meaning
access to vocational/employment opportunities
opportunity for social and economic connections, familial and non-familial
access to health services
onsite assistance in daily living if necessary

Repeated reports in the mainstream news and evaluations by the National Human Rights Commission¹, with the exception of a few hospitals, paint the picture of a persisting problem of lack of rehabilitation options and long stay users in several state hospitals across India. 38% of people in state mental health facilities in India have a duration of one or more years of stay². In facilities such as The Banyan's, while a majority choose to and are able to go back home, a small percentage remain in the institution, several on account of intellectual disability. In the last twenty years of running a transitory hospital based rescue and rehabilitation system for homeless women with mental illness, The Banyan has found approximately 11% of such individuals not exiting the system any way, having no family, choosing not to go and concurrently experiencing long term needs that deter independent living.

Home Again envisions the facilitation of long term care in alternative living spaces, through shared accommodations with supportive services, for women with mental disorders, who were once homeless and experience long term needs. It involves the facilitation of housing and range of supportive services for inclusion into the rural socio-economic fabric through strong inclusion linkages with stakeholders in areas of local governance, employment, entitlements and social activity. Through this approach, we aim to sustainably and in an cost effective manner address the issue of long term care in mental health; and thereby provide pathways for rehabilitation of people in institutional spaces, improve their quality of life, mental health outcomes, community functioning and promote human rights. This will address the challenge of appropriate and humane care for those most marginalised on account of homelessness and serious mental disorders and will most meaningfully contribute if scaled up to address the issue of long stay in state mental hospitals. Therefore, such an approach has the potential to contribute to transformative institutional reform on the one hand, while on the other promote social inclusion and positive notions of mental health in rural communities by setting up potential evidence of outcomes in people with high mental disability.

Key drivers

Flexible, personalised support based on unique needs of each client and a focus on lived experiences, personal well being are critical drivers of this innovation.Transitions from hospital based care to independent living is possible in a graded fashion for persons with mental health issues, experiencing long term needs; provided a dynamic, adaptive and responsive system of care is available that responds to personal needs, distress and crisis. This system has to be monitored carefully with precision, empathy and focus on promotion of interdependence and stimulation of hope, especially during the initial stages.

Challenges

Some problems (chronic mental health issues) remain persistent, although enhanced personal attention seems to help. In some cases, however a shared housing option may not be the best. So a shift back into a high support environment could be sought. Options, choices thus have to be available, as should frequent review systems.

Social Order and challenging notions of the same could pose some difficulty - what is normal? Who lives in a community? Why, when, when not? These discussions are engaged in, only if there are opportunities; and SH provides this implicitly. Everyday social transactions and negotiations impact perceptions and behavior resulting in fresh perspectives among community members, although, an untoward incident can result in a negative spiral sometimes; but a diversity in opinion, thought and attitude helps in arriving at a somewhat balanced view, even within the community, one hopes.

Social order and high dependence on the known and clinically and socially established approaches to mental health care could influence care giving and programme management. Thus care coaches could be in conflict between what was and what should/ could be in terms of autonomy and choice promotion, or facilitating in an intervention. An exercise was thus initiated to arrive at a framework or “code” that would guide these decisions, with a focus on everyday implementation beyond the philosophical or ideological orientation, such that day to day complexities or how much involvement, when, where, on what constitutes a mental health concern or acute distress or crisis etc. are explicitly and uniformly stated and standardised, to the extent possible.

Continuation

Our focus is to demonstrate shared housing as cost effective and viable option, take the innovation to scale in other settings with similar challenges, particularly government and not-for profit institutional facilities; and in the process transform institutional mental health care. This may bring about radical change with implications for larger mental health movement given leadership vested with these facilities.

Partners

The Banyan

Funder:

Grand Challenges Canada (Canada)

Evaluation methods

Quasi experimental design with two groups (non random assignment based on choice), with repeated measures over 18 months to examine effects (once every 6 months) on multiple outcome measures of interest. Ethnographic observations, focus group discussions and in-depth qualitative interviews are being conducted to offer directions,complement and nuance the quantitative enquiry.

Impact details

67 women were shifted into shared housing; 50 women continue to sustain this over the last 12 months, across 11 homes.

92% of women demonstrate gains in community functioning over a 6 month period, with more participation in leisure, shopping and cohesion-co-operation for running of home. Preliminary analysis of data at 6 months from intervention, reveals significant gains in community functioning as indicated by scores on CIQ (Community Integration Questionnaire).

References

National Human Rights Commission (1999, 2012)
WHO World Mental Health atlas, 2011

Tools

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Country

India

Affiliated organizations

The Banyan