An innovative transitional housing pilot program located in Sudbury, Ontario, offers on-site and integrated clinical and social supports. The program integrates the provision of primary healthcare, substance use care, mental health consultations and harm reduction services. A recent study explored participant experiences in, and feedback about, the program and care provided to them. Findings highlight the complex intersections of needs and aspirations among participants transitioning from homelessness to transitional housing settings. The study found that addressing needs through holistic, evidence-based and person-centred harm reduction approaches to facilitate long-term stability and wellness is critically important.
Program description
In January 2022, Health Sciences North and the City of Greater Sudbury launched a transitional housing pilot program designed to meet the complex needs of people experiencing homelessness and facing mental health and substance use challenges. The program uses a Housing First philosophy that integrates harm reduction strategies across healthcare and social support systems.
The program provides immediate access to transitional housing that offers comprehensive health and social support on-site. Services include healthcare, substance use care, mental health services and broader social support to foster wellness and enhance life skills. The program’s aim is to help participants build the skills needed to move into sustained permanent, independent housing. The Housing First approach prioritizes addressing the primary needs of people experiencing homelessness without requiring abstinence or treatment adherence, helping to reduce prolonged homelessness and housing instability.
One of the criteria for admission into the program is a high vulnerability score using the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) assessment. Prospective participants must be registered on the City of Greater Sudbury’s By-Names list, which is used to help manage homelessness, and go through an initial interview to assess their suitability. Participants must be 16 years of age or older, chronically homeless (i.e., for a minimum of six months), interested in securing permanent housing, able to complete activities of daily living and independently mobile. Participants must be assessed as “tri-morbid” (i.e., experiencing physical, mental health and substance use challenges). The harm reduction-based program accepts people regardless of whether or not they are actively using substances. People who require 24-hour support or monitoring, have pets or dependents, or have a criminal record that prevents interactions with minors are not eligible to participate in the program.
Once admitted into the program, participants receive transitional housing for up to 18 months. Each participant has a private room with a bathroom and access to a communal kitchen. Participants are supported by a multidisciplinary team that includes nurses, substance use specialists, social workers, primary care physicians and psychiatrists who collaborate to provide comprehensive wraparound care that addresses both their medical and psychosocial needs on-site. The program actively supports participants in overcoming personal barriers by providing tools to access essential services (e.g., food banks, dental and psychiatric appointments, substance use treatment, legal support, vocational training). The holistic approach aims to enhance well-being and prepare residents for autonomous living by offering specialized care and skill-building tailored to individuals at varying stages of stability in substance use.
Results
Between June and August 2023, 12 residents from the transitional housing program participated in semi-structured interviews. The objective of this qualitative study was to explore and understand participant experiences within the transitional housing program and to gather feedback on how the program can be adjusted and improved. Of the 12 participants:
- approximately 35% identified as female
- approximately 50% identified as Indigenous
- the average age was 30 years
- the average amount of time for being unhoused in the last year was 10 months
Participants identified key factors for consideration, organized thematically by the research team. Maslow’s hierarchy of needs guided the research; it assumes that people are motivated to prioritize and address their needs in a particular order, starting with physiological needs and followed by the needs for safety and security, love and belonging, esteem and self-actualization.
Physiological needs
Participants underscored the significance of having their basic needs met (e.g., stable accommodation) for providing a sense of stability and security in their lives. Once their basic needs were met, they could focus on other challenges such as addressing mental health and substance use concerns and securing permanent housing. Many participants noted an ongoing struggle to meet their basic nutritional needs because of financial constraints and difficulties accessing essential resources like food banks.
“So that’s why I like having a roof over my head. It makes me go forwards, it makes me be better and feel more comfortable and getting my stuff done.”
Safety and security
Participants noted that convenient, low-barrier access to medications (particularly to opioid agonist therapy) within the program was an important factor contributing to positive experiences and feeling safe and stable. Participants reported that support in managing their medications helped them adhere to their medication regimens. Some participants mentioned that it was difficult to find a balance with staff between the need for restrictions to ensure safety and security and the importance of respect for participants’ autonomy and support for practising harm reduction. Because thefts persisted even though participants were housed, many individuals also highlighted the importance of security and continued support to help them address their safety concerns while adapting to new living conditions. By working together with staff, participants were able to discuss what safety looked like to them and what rules were reasonable and enforceable to balance personal freedom with safety and security.
“Well for me it’s good to have, for me not to have to go downtown to get my drink [methadone]. I like that I don’t have to go downtown, and I do my samples here too.”
Love and belonging
Participants valued the sense of community and belonging fostered in the program among staff and residents. They reported feeling accepted and supported and noted the importance of inclusive, person-centred policies around visitation from family and social supports. Some participants expressed a desire for greater connections with loved ones through visits and advocated for more flexibility around visitation rules, while acknowledging the need for rules to maintain order.
“And I feel very much accepted here, not only by the staff, but the clients as well. It’s very much a little family.”
Esteem
Many participants reported that building their independence and self-worth were significant aspects of the program and expressed pride in their achievements (e.g., obtaining identification, improving their personal hygiene, pursuing educational and vocational opportunities). Participants noted that by providing practical assistance and emotional support, supportive staff played an important role in enhancing their self-esteem. Participants expressed that equitable treatment among residents, inclusive decision-making processes and allowing residents to decompress when entering the program helped participants adapt and contributed to their overall stability.
“Knowing that I am doing something with my life. I’m involved with [name of organization], and it makes me proud. I’m capable and this is the time.”
Self-actualization
Participants noted their ambitions for personal growth and strong motivations to improve their circumstances and pursue new opportunities beyond their current situation (e.g., further education, career development). Many participants expressed a need to be recognized for their efforts and accomplishments beyond their substance use and noted a desire to be acknowledged for personal growth in other areas of their life (e.g., mental health, relationships, personal development).
“Even though we’re not meeting the requirements of quitting drugs you know, at least we’re — I’ve changed because of this program; rethinking who I am and how I treat other people.”
What does this mean for service providers
Findings highlight the complex interplay of participant needs and aspirations when transitioning from homelessness to transitional housing. They also highlight the critical importance of providing integrated, comprehensive health and social supports to help people to achieve stability, personal growth and sustained independence and wellness. On the basis of information provided by participants, the program was able to revise its visitation policy and other program features such as food availability and person-directed goal setting. The program supported the delivery of empathetic, person-centred support services that respect personal autonomy and independence while also fostering a sense of community and belonging. To facilitate successful transitions to independent living and long-term stability, service providers could consider transitional housing programs that recognize the multifaceted needs and aspirations of participants and provide wraparound supports.
Related resources
Hepatitis C testing and treatment within supportive housing sites – CATIE article
A flexible and mobile approach to hepatitis C care delivery for people experiencing homelessness – CATIE article
Enhanced Supportive Housing Program – CATIE case study
Reference
Morin KA, Aubin N, Molke D et al. Perspectives on a transitional housing program for people who use substances who experience homelessness and live with a mental health issue: a pilot study in an urban northern city in Canada. Substance Abuse Treatment, Prevention, and Policy. 2025;20(20):1-8. Available from: https://doi.org/10.1186/s13011-025-00649-7