Programming Connection

RainCity Housing and Coast Mental Health Housing Initiatives 

Vancouver STOP Project
Vancouver, British Columbia
2013

Connecting the Dots from Housing to Health

For people living with HIV in Vancouver who are homeless, under housed or street involved, finding safe and suitable accommodations can be difficult with a lack of options. This is starkly demonstrated by the existence of long waiting lists for HIV-specific housing in Vancouver, as elsewhere. As of 2011, these lists had more than 400 clients on them in some cases, representing an estimated wait time of more than two years. For some people, the added challenges that can accompany trauma, addictions or mental health concerns often lead to situations in which accessing and adhering to an HIV treatment regimen may be difficult, impossible or simply not a priority. For people in these situations, HIV infection can go uncontrolled for a long time, significantly damaging the immune system. That, in turn, can allow the virus to develop resistance to treatments, leading to AIDS and even death. Housing can often be the missing link required to get to the point where managing one’s HIV infection is a realistic priority.

In recognition of the lack of accessible, affordable housing options for people living with HIV in Vancouver, the Vancouver STOP Project, the team responsible for the implementation of the STOP HIV/AIDS Project in this city, partnered with RainCity Housing and Coast Mental Health. The following Program Element describes these partnerships as well as the three innovative strategies they used to address the urgent housing needs of Vancouver STOP Project clients: a housing stabilization support program; supported independent living subsidies (SILS); and access to units in a supported housing building.

Making Links to Housing

Rather than develop a separate housing strategy for clients parallel to other housing agencies in Vancouver, the Vancouver STOP Project partnered with and funded two established housing providers that offer services to a broad range of people in the city, including but not limited to people living with HIV: RainCity Housing and Coast Mental Health.

Both RainCity Housing and Coast Mental Health have proven track records in providing housing solutions for people living with mental illness, addictions and other health challenges. Since 1982, RainCity Housing has provided progressive, compassionate shelter and housing to people in the Lower Mainland who are living with mental illness, addictions and other challenges. Coast Mental Health was established in 1972 and provides housing, employment, community and emotional support for people living with mental illness by providing practical support.

Each agency was funded to hire 1.4 additional full-time equivalent housing workers. These staff work almost exclusively with clients living with HIV and are intensively engaged with a city-wide, clinical HIV outreach team, also funded by the Vancouver STOP Project, called the STOP Outreach Team. This team is an interdisciplinary group of nurses, outreach workers, social workers, peers and others who work to expand access to low-barrier HIV services and improve engagement in HIV treatment, care and support for some of Vancouver’s most marginalized people.  

The partnership that was established and solidified by the newly funded housing workers is unique.  These staff members were intentionally hired to act as a critical link between the STOP Outreach Team and the support required to obtain and maintain housing. These initiatives allow for a level of integration rarely seen between healthcare providers and housing workers. This often involves daily or even hourly communication about clients so that all members of the team are ready and able to provide support for any crisis or time-sensitive situation. For more information on this team, please see the STOP Outreach Team case study in Programming Connection.

While it may seem obvious that having appropriate, stable housing is important to people’s health, the relationship between health and housing is complex. Not only does housing affect health, but people’s health -- including their possible substance use, mental health concerns and stage of HIV infection -- can significantly affect the type of housing best suited to them, as well as the support required to obtain and maintain it. For clients whose health concerns had historically made it difficult or impossible to find stable housing, the extra support provided by this collaboration allowed for deeper insight and flexibility into their unique needs. 

Tailored Housing Solutions

No single housing solution is desirable, suitable or appropriate for every person. For example, while some people may appreciate and greatly benefit from housing that integrates support such as medication dispensing/reminders and regular meals, others may fare better simply having access to independent living. Similarly, the type of housing support people require can vary widely. For someone dealing with homelessness, it may mean simply having a safe bed to sleep in; for others, it involves help moving from temporary to more long-term housing. Some people simply need short-term assistance to maintain the housing they already have.

The role of the housing workers funded by the Vancouver STOP Project was not only to help homeless STOP clients find housing, but also to provide any support required to obtain and maintain it. This additional support consisted of assistance with connections to community health and social service resources, move-in and move-out assistance, coaching in the acquisition and maintenance of independent living skills, advocacy in legal and medical affairs, and intervening in crisis situations that might affect the clients’ health and/or tenancy. This extra support proved to be very important in ensuring STOP clients’ ability to maintain their housing. For some clients who came from extended periods of homelessness, adjusting to living in more collective spaces where community norms required particular behaviours (such as attention to noise) sometimes proved challenging. Given the importance of stable, consistent housing in adhering to treatment and effectively managing their HIV infection, this additional support proved to be the key that could make the difference between clients’ maintaining housing or facing eviction.

The Vancouver STOP Project funded three different types of initiatives to address these varied needs.

Stabilization Support Program

At any given time, a minimum of 10 Vancouver STOP Project clients were connected to the Stabilization Support Program at RainCity Housing. Clients referred to this program by the STOP Outreach Team were homeless, almost or totally disconnected from any services, and in a moderately or extremely poor state of health. In these situations, when the STOP Outreach Team agreed with a client that finding access to housing was a priority, the housing outreach worker at RainCity Housing was called to provide support in the process of finding suitable housing, transitioning into that housing, and maintaining the housing once it was found.

Having a dedicated housing outreach worker at RainCity Housing was a deciding factor between remaining homeless and being able to access more stable housing for many STOP clients. The housing outreach worker could facilitate access to shelter beds at RainCity Housing, and was also well acquainted with the other shelter and housing options throughout Vancouver.

Even though the housing outreach worker was based at RainCity Housing, a great deal of work was done outside of the office as the structure of the Stabilization Support Program was not restricted to finding housing locations at any particular agencies or locations. This allowed flexibility to work with clients wherever they were and to continue providing support throughout the entire transition from homelessness to housing, even if the client’s needs changed or they were evicted. Importantly, even after clients were discharged from the housing outreach worker’s active caseload, the worker gave priority to supporting the client in a crisis if their housing became threatened at any time. This integrated and flexible collaboration between a client’s housing and other support providers, such as the STOP Outreach Team nurses, enhanced the overall level of support each could give to their clients, at all points in the process of finding and maintaining housing.

Supported Independent Living Subsidies (SILS) – Temporary and On-Going

Some Vancouver STOP Project clients who were homeless and referred to RainCity Housing’s housing outreach worker did not fare well in supportive housing situations. For these STOP clients, moving directly into independent market housing was the best fit, rather than transitioning through shelters or other more temporary solutions. While disability assistance in B.C. provides about $375 per month for shelter, low-rent independent housing buildings can cost from $600 to $1,000 per month, if not more. Through the SILS project, approximately 10 people were offered a rent subsidy of up to $400 per month, which acted as a top-up to ensure they could get and maintain housing they might not have been able to afford otherwise. This money could make the difference between homelessness and decent housing. SILS therefore acted as a buffer to help those clients on the edge of homelessness because of a gap between their income and living expenses.

Temporary SILS

One of the interesting innovations that arose from the RainCity Housing-STOP partnership was the idea of temporary SILS. This variation on the more long-term SILS grew from the realization that, for many clients, it was not on-going financial assistance that was required, but financial help with one-time or short-term situations where their income was not sufficient to get or maintain housing. Temporary SILS were often useful during periods of transition for STOP clients, mostly when an appropriate housing option became available but the costs associated with moving into that housing, such as damage deposits or first and last months’ rent, were too high.

Another relatively common situation occurred when STOP clients found suitable housing that was only slightly more expensive than the $375 provided by disability assistance. In these situations the client, supported by the housing outreach worker, was sometimes able to obtain the additional financial support required, but needed a small, short-term top-up until their applications for such support was processed and approved.

For clients accessing addictions recovery programs and taking antiretroviral (ARV) medications and methadone, becoming homeless for even short periods of time can mean huge setbacks and result in many of these achievements unravelling. For these clients, SILS proved to be extremely important to obtaining stable housing or taking advantage of better housing opportunities when they arose.

Access to Supportive Housing

Serendipitously, Coast Mental Health was preparing to open a nine-storey, 96-resident supported housing building (the Pacific Coast Apartments) at the same time the Vancouver STOP Project was getting underway. This building was specifically intended to provide housing for people who would otherwise be homeless, at risk of homelessness, or living in substandard housing. Given the considerable support infrastructure integrated into this housing, including a 24-hour on-call clinical service, pharmacy and property management, this site was a good fit for those STOP Project clients who could benefit from housing that also provided extra support. For clients who were on but not able to adhere to their ARV treatments, the added assistance of daily meals and medication reminders helped them achieve a consistent routine and gave them increased stability.

Providing supportive housing to STOP clients at the Pacific Coast Apartments resulted in a range of outcomes, many of which are not immediately apparent when looking at project reports or statistical evaluations. For example, some clients who had been homeless for long periods of time were so ill when they finally accessed housing that their HIV infection (and other health concerns) could not be controlled; for these clients, the housing functioned like a hospice where they were cared for and were able to die in a respectful environment. For others, the additional support and stability gave them the time needed to gain weight, access services such as addictions treatment, and eventually reach a state of health and well-being that they could seek and maintain independent housing. Staff noticed that even clients who eventually left the housing because they did not like the structured support and communal environment often left healthier and better rested than when they entered. This allowed many STOP clients to improve access and adherence to their treatment regimens and for some it resulted in dramatic increases in CD4 counts.

From Housing to Health

The partnerships with housing agencies developed through the Vancouver STOP Project revealed just how important the integration between housing and health really is, and how much of a difference access to appropriate housing can make. For instance, as of January 2012, Coast Mental Health had filled 23 out of 25 units. On admission, only 12 percent (three people) had a viral load less than 200 copies/mL. In a matter of months, 76 percent had a viral load less than 200 copies/mL.

These collaborations demonstrated that while housing is a vital component of people’s ability to adhere to their HIV treatment regimen, a great deal of other support must be in place for them to take advantage of newly found housing. These supports, which can be medical, social or financial, work best when they come from an integrated team of service providers who work together flexibly to provide unique and tailored assistance to STOP clients who are homeless or at serious risk of homelessness.