Developing Housing For Persons With Severe Mental Illness: An Innovative Community Foster Home
Assistant Professor, Department Psychiatry, Faculty of Medicine, and
Assistant Professor, School of Social Work, McGill University
Nurse Manager, Department of Psychiatry, McGill University Health Center, (adult sites)
Chief of Service, Residential Resources, Douglas Hospital
Montreal General Hospital
Team Leader - Psychiatry and
Douglas Hospital Rsearch Centre
Piat, M., Wallace, T. Wohl, S., Minc, R., Hatton, L. (2002) Developing housing for
Persons with severe mental illness: an innovative community foster home.
International Journal of Psychosocial Rehabilitation. 7, 43-51.
Mailing address: Dr. Myra Piat, Douglas Hospital, 6875 LaSalle Boulevard, Verdun, Quebec Canada H4H 1R3.
Telephone: (514) 761-6131 Fax: (514) 888-4071
Objective: The objective of this study was to evaluate an innovative housing project that integrated a nursing assistant into a foster home for persons with a severe mental illness. The residents who were evaluated had tried to live in the community on numerous occasions, but their attempts had failed, and they returned to hospital for long periods of time.
Methods: The study sought to explore the perceptions of four different stakeholder groups: (1) residents living in the home (2) the nursing assistant (3) the foster home caregiver and (4) the multidisciplinary team. Semi-structured interviews and self-report questionnaires were used to gather the data.
Results: Findings suggest that individuals suffering from severe mental illness, who previously could not function outside of an institutional setting, can settle well into a community environment. The overall time spent in hospital by the residents one year pre-and post-evaluation differed greatly (in total 650 days before versus 124 days after placement). Supportive relationships were formed between the residents, nursing assistant and caregiver. The factors contributing to the success, as well as those elements that require improvement are discussed.
Conclusions: Residents were able to live in a community for the first time. Innovative ways of changing current housing structures should be considered in order to foster adjustment of these difficult to place individuals into the community. _________________________________________________________________________________________
This article reports on the evaluation of an innovative foster home for persons with severe mental illness in Montreal, Canada. Over the past four decades numerous forms community based housing have been developed to meet the needs of deinstitutionalized persons with mental illness. Group homes, supervised hostels, foster homes, supervised apartments, and other forms of supported housing were created to meet the needs of these individuals (Trainor, Morrell-Bellai, et al.1993). In Montreal, Canada, the majority of patients discharged from long-term wards of psychiatric hospitals were placed into foster homes. Traditionally, these homes provided stable housing for those people unable to maintain themselves independently in the community.
Although in recent years emphasis has shifted to other forms of alternate housing, such as supervised apartments and supported housing, foster homes are still viewed as an important residential resource for persons with serious mental illness . In certain cases, living in a foster home remains the only realistic long term housing option as patients discharged from psychiatric hospitals have lost contact with family members, and have few social supports. Often placement into a foster home is the ex-patientís permanent home and primary link to the community. In Montreal, Canada foster homes make up 51% of subsidized housing available for persons with psychiatric disorders .
Characterized as ordinary homes in the community, foster homes are regulated by the Law Respecting Health and Social Services (Bill 120). Unlike other external services for persons with serious mental illness, which rely heavily on professional staffing (i.e. Assertive Community Treatment), non professionals operate foster homes. No specific training is required to become a foster home caregiver. Foster home caregivers work in close collaboration with hospital multi-disciplinary teams, in which a case manager and a housing worker are assigned to each foster home. The multidisciplinary team oversees the overall well being of clients placed in the foster home, and responds on a case-by-case basis, when problems or crisis situations arise.
In recent years emphasis has shifted dramatically to other forms of alternative housing, such as supportive and supported housing (Carling, 1993, Hogan and Carling, 1992, Parkinson, Nelson and Horgan, 1999, Ridgway and Zipple, 1990, Srebnik, Livingston et al, 1995). Although these types of housing are popular, and may be beneficial to some persons with serious mental illnesses, there remains a group of individuals who are unable to live within the existing housing structures, and are currently occupying beds in acute care hospitals. These individuals deserve the opportunity to live in a community environment. This is not possible without the development of new approaches to support residents and caregivers in the community.
The impetus for this innovative housing project grew out of the need to develop a new housing model for a group of persons with severe mental illness currently occupying hospital beds, and unable to live within the existing housing structures. Typically, this group of "difficult to place patients", has been through the system, has a history of unsuccessful community placements, but cannot be stabilized, and thus has nowhere to go except back into hospital.
Coupled with this service need was the fact that nursing assistant positions were closed in a teaching hospital in Montreal, in the Department of Psychiatry. Individuals who previously held these positions were given the opportunity to relocate to community-based foster homes. This provided a good opportunity to test the effectiveness of transferring skills obtained in a hospital setting to the community. Researchers have suggested that nursing assistants are the primary direct caregivers of residents in long-term care facilities for the elderly (Maraldo, 1991). Studies have shown that nursing assistants form close relationships with patients, and they suggest that quality of care is based on the quality of this relationship (Bowers, Esmond & Jacobson, 2000; Schirm, Albanese, Garland, et al., 2000).
This innovative housing project, the first of its kind in Montreal, integrated a nursing assistant into a foster home. While working with the residents in the foster home, a nursing assistant would function as a support and educator/trainer for the caregiver through role modeling the skills and attitudes necessary to care for this clientele. Sickman and Dhooper (1991) found that in a sample of foster home caregivers, a positive relationship existed between caregivers that had some form of health care training and competencies in caring for the mentally ill.
An Overview of the Literature
A great deal of research has focused on the outcome of placement into residential facilities including: community tenure, community integration, housing stability and quality of life. Most often community tenure and re-hospitalization are used as the criteria for measuring success. Carpenter reviewed over 60 outcome studies of psychiatric patients. This included studies that examined the environment, patient selection, staffing, programming, and length of stay. Findings confirmed that it was less costly to house persons with mental illness in the community than in hospital. Murphy, Engelsmann and Tcheng-Laroche used patient characteristics to measure outcome, and reported that patients living in foster homes showed no improvement in social functioning after 18 months. Another study contradicted these findings as foster homes improved social functioning within four months regardless of patient characteristics . Recent studies (Newman, 2001, Goering, Cochrane, Durbin, et al., 1997) that reviewed the relationship between housing attributes and serious mental illness concluded that while research has examined the various characteristics, experiences and outcomes of the different housing models for deinstitutionalized persons, few conclusions can be made about the effectiveness of any one model. Other studies have suggested that the characteristics of the environment are more predictive of outcome than the characteristics of the individual .
The objective of this study was to evaluate the implementation of this innovative project that integrated a nursing assistant into a foster home for persons with a severe and persistent mental illness. Given that this project was in operation for only 6 months at the time of the study, the focus was on the implementation phase. The evaluation sought to explore the perceptions of the four different stakeholder groups involved in this pilot project: (1) the residents living in the home (2) the nursing assistant (3) the foster home caregiver and (4) the original planners. The factors contributing to the success of the foster home, as well as those elements that require improvement were identified and will be considered further in the Discussion section of this paper.
Description of Project
A multidisciplinary team from a large teaching hospital in Montreal, Canada identified a number of individuals with a severe mental illness who would be good candidates for this housing project. These were people who had been hospitalized from several months to over one year and had already lived, unsuccessfully, in various types of housing in the community. A nursing assistant on staff at the hospital volunteered to be reassigned to the community to provide support to the caregiver of this foster home. A multidisciplinary team of health care professionals was assigned to provide frequent follow-up for the residents. Each groupsí profile is detailed below.
Six individuals (5 males and 1 female) ranging in age from 24-54 years were placed from an acute care hospital into the foster home, though only four of these residents agreed to participate in the study. All residents were diagnosed with schizophrenia and all had an extensive history of unsuccessful community placement and repeated hospitalizations. Previous living arrangements included the Salvation Army, rooming houses, and homelessness.
The caregiver had previously worked as a teacher and though he had no specific experience with this clinical population, he had the potential and enthusiasm to take on this challenge. Prior to accepting the residents, the caregiver visited the hospital in order to get acquainted with those patients who would be moving into the home. The caregiver was responsible for the overall functioning of the home. He lived on the premises and provided room and board, and supervision for the residents. He also had a network of extended family who were able to provide support to him in the home. The caregiver assisted in the implementation of the treatment plan, developed for each resident living in the home.
The nursing assistant who chose to work in the foster home was an employee of the hospital for 27 years. He had extensive experience working with a psychiatric population in an acute care setting, and was familiar with all of the residents as a result of his work in the hospital. It is important to note that this nursing assistant had always worked in an institutional setting, and no specific training was provided to him in this pilot project. Unlike the rotation work pattern of a hospital, he maintained a regular Monday-Friday, eight-hour day, work schedule. Using a "hands-on" approach in the home the nursing assistantís role was twofold: (1) to support residents living in the home, and (2) to act as a role model for the foster home caregiver. Given his previous experience with this population, the nursing assistant provided intensive intervention with residents on a daily basis. For example, the nursing assistant had knowledge of patientsí medications and previous experience working with the multidisciplinary team. The nursing assistant supported the caregiver and assisted him in the day-to-day management of the residentsí activities of daily living. Ultimately, it was hoped that the nursing assistant would transfer his knowledge and expertise to the caregiver. This would entail on the job training, education and support for the caregiver with the goal of maintaining this difficult population in the community.
This hospital-based multidisciplinary team, composed of a psychiatrist, a social worker and a nurse, visited the foster home on a bi-weekly basis. This team provided regular on-going support and guidance to the caregiver and nursing assistant. The team assessed problem behaviors and proposed adjustment of medications. The nurse was available to assess problematic situations, and acted as the contact person for emergency consultations. The social worker dealt with the administrative tasks such as welfare payments, and access to community resources. The psychiatrist was viewed as a key player in the home. He participated in team meetings, reviewed medications and met with the residents individually if required.
The housing worker was involved in the foster home from the outset and coordinated the implementation of the project. She was responsible for supporting and supervising the caregiver, as well as ensuring the foster home was functioning adequately.
When the project was in place for 6 months, an evaluation committee was organized to assess the foster homeís effectiveness. Data was collected in 1999-2000.
In order to develop descriptive information about the residents living in this foster home, a short questionnaire was drafted and included the following data: demographic information, hospitalization and placement history, and family involvement. Patient hospital files were also consulted to provide a more detailed description of the patientsí housing trajectories.
Semi-structured interviews were conducted with (1) residents living in the group home at the time of the evaluation; (2) the caregiver; (3) the nursing assistant; and (4) the planners and multidisciplinary team. A group interview format was used to interview the residents living in the foster home. Residents were asked about their lives prior to arriving in this residential setting, how this home compared to other living arrangements, and what suggestions they had for improving the foster home. Individual interviews were conducted with the nursing assistant and the caregiver. The same interview guide was used for both. Each respondent was asked to describe the program, his responsibilities, whether the project had reached the targeted population and the strengths and weaknesses of the project. A group interview was held with the original planners of this pilot project and the hospital-based multidisciplinary team.
Interviews lasted between 60 and 90 minutes. All except the group interview with residents were tape recorded and transcribed verbatim. Detailed notes were taken in the group interview with residents in the foster home. Data was then organized into two major themes (1) factors contributing to the success of the home and; (2) factors that created obstacles that may be improved.
Participation in the study was voluntary. People were free to refuse to participate or to answer any specific question(s). Residents were first approached by the Nurse Manager and asked whether they would be interested in participating. Residents participating in the group interview gave their informed consent and were given a small financial compensation for their participation. In reporting the findings, every effort was taken to ensure confidentiality, and no identifying information has been used.
Data was collected on the pattern of hospitalizations for the residents in the year prior to and after they moved into the foster home. Residents were taken to the Emergency Department slightly more frequently after moving into the foster home (12 visits prior to placement versus 15 visits post placement). However, the one-year pre and post analysis of hospitalization differed greatly -in total 650 days before versus 124 days after placement. The disparity in hospital costs for these residents for the year before and after living in the community was calculated to be $455,000 and $86 800 respectively.2 Although these costs comparisons are at best approximate they suggest that this type of community resource can provide an important alternative to hospitalization, in terms of cost.
During the evaluation process, the stakeholder groups were asked to provide feedback on the functioning of the foster home. These groups reported on the elements of the home that were beneficial to its success, as well as the areas that required improvement.
The residents expressed their overall satisfaction with the foster home, preferring it to others they had lived in. The residents felt that the foster home provided a home-like environment, in which they felt they belonged. The residents appreciated the structure and routine that was put into place. They felt that the nursing assistant played an important role in resolving daily problems. The residents also appreciated the administration of their medications.
The residents had some complaints around the day-to-day functioning of the home. They found that the location was not convenient, that a group-living situation was not ideal, and that noise levels were sometimes disruptive. Some residents also found the food to be unsatisfactory, and policies around smoking cigarettes to be inconvenient.
The nursing assistant acted as a model for the caregiver in his interactions with the residents, and the caregiver learned how to handle most difficult situations. This knowledge fostered confidence in the caregiver to resolve problems by himself. The caregiver was enthusiastic in describing the residentsí development and stability after a short time in the foster home. He also highlighted the sense of "family" and security that the residents gained from being in the home. The structure allowed the residents to engage in activities outside of the home. A sense of trust between the caregiver and residents fostered positive communication between them. The caregiver described the nursing assistantís presence in the home as invaluable. The nursing assistant also provided structure and routine in the home, ensuring that self-care tasks were completed and medications taken. The multidisciplinary team provided much needed support to the caregiver.
However the caregiver found that an unequal distribution of work existed between himself and the nursing assistant as the caregiver was on call 24 hours a day, and the nursing assistant was only available for 8hours a day. Though an emergency system was supposedly available to the caregiver at all times, this system proved inadequate after-hours, leaving him responsible to resolve crises himself. Finally, the caregiver would have liked to resolve the problem of finding suitable daily activities for each resident, as they all had various interests.
The nursing assistant found that close relationships had formed among himself, the residents and the caregiver, and felt that low resident turnover and low rate of re-hospitalization was attributableto these relationships. He believed the residents were fairly comfortable in the home and were averse to the idea of returning to hospital. The nursing assistant found that the multidisciplinary teamís involvement had a positive impact on the foster home, as the team provided support and feedback to the nursing assistant when problems arose.
However the nursing assistant found communication between himself and the caregiver was insufficient. He also found that the responsibilities expected of him were not clearly defined at the outset and that overlap occurred with the caregiver when performing certain tasks.
Although the multidisciplinary team was not involved in the implementation of the first stages of the foster home, but was called in after the home was established, they stated that the residents adapted well to the community environment. The teamís biweekly visits provided the caregiver with support through easy access to the psychiatrist (e.g. changing medications when required), as well as the nurse (e.g. providing knowledge for the nursing assistant around out-patient issues).
However the multidisciplinary team found that the mandate of the foster home was not clear, creating confusion around the issue of rehabilitation versus maintenance of the residents. The caregiver and nursing assistant were working Ďin parallelí with the residents, but with different goals. The team found that communication between the caregiver and nursing assistant was inadequate and that the roles of the nursing assistant, caregiver and even their involvement, were not clearly defined at the outset of the project.
Areas of Consensus
All groups agreed that the residents were stable in the community for the first time. This stability allowed for trusting relationships to form and positive communication between the residents and the caregiver and nursing assistant. The three staff groups agreed that the roles of the caregiver, nursing assistant and multidisciplinary team were not adequately defined before the implementation of the project. Inadequate communication between the caregiver and nursing assistant was agreed to be a factor that needed improvement.
Overall the implementation of this innovative foster home has proven to be a success. The residents, who in the past were unable to adjust to living in the community, were able to settle into this environment. The stability of these residents in the home resulted in the formation of trusting relationships with the caregiver and nursing assistant, and consequently a more home-like environment for the residents.
The findings suggest that the support provided to the residents by the caregiver and nursing assistant had a positive impact on the functioning of the home. Researchers have found that a positive relationship exists between an individualís social network and their well-being (Hall & Nelson, 1996; Nelson, Hall & Walsh-Bowers, 1998). The residents of the foster home appreciated the accessibility of the nursing assistant for the provision of medication, the resolution of problems, and other forms of support. The caregiver was available around the clock if problems arose, and acted as a family member to the residents, enhancing their support network.
The support that was available for the caregiver was also an important factor in the success of the foster home. The nursing assistantís experience with this population was instrumental in teaching the caregiver helpful methods of interacting with the residents and resolving problems as theyarose. The caregiver was also able to depend on the nursing assistant for help, which fostered his confidence in running the home.
As a result of this evaluation process, several factors were identified that require improvement. A mandate describing the function of the foster home may help to eliminate problems around conflicting expectations of staff. For instance, the organizers of the project did not define whether the aim of the home was to rehabilitate the residents or simply to maintain them in a community environment. This proved to be an important factor for the caregiver and nursing assistant. By defining the function of the home at the outset, both the nursing assistant and caregiver could have worked together more effectively to meet the objectives of the home.
Clarification of roles for the caregiver, nursing assistant and multidisciplinary team may help to eliminate conflicts. The lack of formal job descriptions for the caregiver and nursing assistant caused overlap in tasks during the day, and left the caregiver solely responsible after work hours. Decisions regarding workload could have been defined at the outset, and problems would have been eliminated. Training of the caregiver and nursing assistant may have improved the functioning of the foster home (Raskin, Mghir, Peszke et al., 1998). The nursing assistant, who had no experience working in the community would have been more effective to the caregiver had he understood the differences of working in the community as opposed to an institutional setting. The caregiver would have benefited from training as well. Raskin et al. (1998) found that the introduction of a psycho educational program for caregivers, which involved the provision of information about the population they were caring for, as well as contact with other caregivers, resulted in decreased re-hospitalizations for the residents in their care.
The multidisciplinary team felt that they were not as focused on the residents as they could have been because they spent a great deal of time involved in discussions with the caregiver around issues related to the functioning of the home. This problem could have been resolved with clear job descriptions given to all stakeholder groups involved.
Despite these areas requiring improvement the findings from this study suggest that individuals suffering from severe mental illness, who previously could not function outside of an institutional setting, can settle well into a community environment. Innovative ways of changing current housing structures should be considered in order to foster adjustment of these difficult to place individuals. This study has demonstrated that the introduction of a nursing assistant into a foster home to provide knowledge and training to the caregiver, as well as a direct hands-on approach, is one method of structuring the community environment for these individuals. Future studies can use this method, as well as resolve the problems that were found in order to formulate a housing structure that will meet the needs of certain individuals with severe mental illness.
Finally it should be noted that 5 of the 6 original residents of the foster home are still currently residing there at this time (24 months later) and the nursing assistant has moved on to support another first time group home caregiver. This project inspired other Montreal based hospitals to integrate nursing assistants into residential teams working in the community.
Carling P: Housing supports for persons with mental illness : Emerging approaches to research and practice. Hospital and Community Psychiatry 44:439-449, 1993
Dorvil H, Guttman H, Ricard N, et al: Defi de la reconfiguration des services de santé mentale: Pour une réponse efficace et efficiente aux besoins des personnes atteintes de troubles mentaux graves. Québec: MSSS, 1997
Goering P, Cochrane J, Durbin J, et al: Best practices in mental health reform. Health Systems Research Unit, Clark Institute of Psychiatry, Toronto, 1997
Parkinson S, Nelson G, Horgan S: From housing to homes: A review of the literature on housing approaches for psychiatric consumer/survivors. Canadian Journal of Community Mental Health 18:145-164, 1999
Hogan M, Carling P: Normal housing: a key element of a supported housing approach for people with psychiatric disabilities. Community Mental Health Journal 28:215-226, 1992
Maraldo P J: Quality in long-term care. In Mechanisms of quality in long-term care. New York, National League for Nursing, 1991
Bowers B, Esmond S, Jacobson N: The relationship between staffing and quality in long-term care facilities: Exploring the views of nurse aides. Journal of Nursing Care Quality 14:55-64, 2000
Schirm V, Albanese T, Garland T, et al: Caregiving in nursing homes. Clinical Nursing Research 9:280-297, 2000
Sickman J, Dhooper S: Characteristics and competence of care providers in a veterans affairs community residential care home program. Adult Residential Care Journal 53:171-184, 1991
Hall GB, Nelson G: Social networks, social support, personal empowerment, and the adaptation of psychiatric consumers/survivors: Path analytic models. Social Science and Medicine 49:1743-1754, 1996
Nelson G, Hall GB, Walsh-Bowers R: The relationship between housing characteristics, emotional well-being, and the personal empowerment of psychiatric consumer/survivors. Community Mental Health Journal 34:57-69, 1998
Newman, S: Housing attributes and serious mental illness: Implications fro research and practice. Psychiatric Services 52:1309-1317, 2001
Raskin A, Mghir R, Peszke M, et al: A psychoeducational program for caregivers of the chronic mentally ill residing in community residencies. Community Mental Health Journal 34:393-402, 1998
Ridgway P, Zipple A: The paradigm shift in residential services: From the linear continuum to supported housing approaches. Psychosocial Rehabilitation Journal 13 :11-31, 1990
Srebnik, D. Livingston, J. Gordon, L and King, D. Housing choice and community success for individuals with serious and persistent mental illness@. Community Mental Health Journal 31:139-152, 1995.
Trainor, J, Morrell-Bellai,T., Ballantyne, R., Boydell, K Housing for people with mental illness: A comparison of models and an examination of the growth of alternative housing in Canada@. Canadian Journal of Psychiatry, 38: 494-500 1993
Copyright © 2002, Hampstead Psychological Associates,
Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved. A Private Non-Profit Agency for the good of all, published in the UK & Honduras.