This thesis responds to the lack of psychiatric and infrastructural support during the transition from inpatient to outpatient care, and proposes a supportive housing model for patient recovery. It establishes an architecture to support a new model for mental health care using the bio-psycho-social perspective outlined in the psychological research section. Research into different methods of treatment, perception, and current patient infrastructure reveal that the existing framework does not suit the needs of patients caught between the secure levels of care in forensic institutions and those recovered enough to sustain themselves. The psychiatric program is based on the bio-psycho-social perspective outlined in the psychology chapter of the thesis, which will be used to treat patients with schizophrenia, mood disorders and anxiety disorders. The architecture is designed to support this perspective, and is based on the research into perception and the architectural strategies needed in the design of a healing environment: community, security and privacy, patient control including spatial intelligibility, haptic and basic orientation, light, sound and positive distraction. The design is proposed for the Moss Park area in Toronto: where the actual site itself stretches from Dalhousie Street and Queen Street East to Mutual Street and Shuter Street. Its history and current amenities make it an ideal location for a design proposal, though multiple locations are envisioned across the GTA. The design presented in this thesis is envisaged as part of a network of varying care levels: follow-up care, supportive care and comprehensive care. The program for the site will consist of the supportive care programming, which is the middle level of care.

This thesis responds to the lack of psychiatric and infrastructural support during the transition from inpatient to outpatient care, and proposes a supportive housing model for patient recovery. It establishes an architecture to support a new model for mental health care using the bio-psycho-social perspective outlined in the psychological research section. Research into different methods of treatment, perception, and current patient infrastructure reveal that the existing framework does not suit the needs of patients caught between the secure levels of care in forensic institutions and those recovered enough to sustain themselves. The psychiatric program is based on the bio-psycho-social perspective outlined in the psychology chapter of the thesis, which will be used to treat patients with schizophrenia, mood disorders and anxiety disorders. The architecture is designed to support this perspective, and is based on the research into perception and the architectural strategies needed in the design of a healing environment: community, security and privacy, patient control including spatial intelligibility, haptic and basic orientation, light, sound and positive distraction. The design is proposed for the Moss Park area in Toronto: where the actual site itself stretches from Dalhousie Street and Queen Street East to Mutual Street and Shuter Street. Its history and current amenities make it an ideal location for a design proposal, though multiple locations are envisioned across the GTA. The design presented in this thesis is envisaged as part of a network of varying care levels: follow-up care, supportive care and comprehensive care. The program for the site will consist of the supportive care programming, which is the middle level of care.

This research explores the subjective experiences of women with mental health challenges residing in a supportive housing building in Southern Ontario. Drawing on principles of Feminist Participatory Action Research (FPAR), five women were brought together to engage in an arts-based workshop meant to provide the opportunity to reflect on their experiences, express themselves through alternative means, and connect with peers over shared experiences. Over six meetings, participants have been invited to contribute to group discussions by taking and analyzing photos that represent their journey while living in supportive housing. Drawing on a critical feminist and Mad Study scholarship, this project used intersectionality as its theoretical lens. This choice intends to emphasize the interconnected and compounded system of oppression that women experience when their identity intersects across various dimensions such as gender, gender expression, race, mental health status, class, and more. This research is essential because of the pervasiveness of discrimination, disempowerment and oppression of people diagnosed with a ‘serious mental illness’ and how these infiltrate relationships and social systems. However, little empirical data exists to explore the in-depth perspective of these individuals, who lack power and voice in society. In particular, women with a psychiatric diagnosis live at the intersection of multiple oppressive factors. Thus, to counterbalance oppression, it is essential to recognize these women as the experts in their lives. Moreover, women’s active participation in research and their photographs and stories offered a nuanced understanding of issues affecting them. From the photographs (visual data) and the meaning given by participants through their stories (narrative data), issues emerged related to stigmatization, gender-based violence, economic limitations, inadequate support, and various forms of discrimination. Furthermore, participants expressed their insights into desired changes within and beyond the supportive housing program. The relevance of this research is threefold: 1) it gave agency to women living in supportive housing to outline their unique needs and wants; 2) it contributed to the paucity of qualitative research situated at the intersection of gender and ‘mental illness’; 3) through KTE activities, it has the potential to inform housing and helping professionals on ways to improve housing projects, design activities, and foster residents’ engagement for this population group. / Thesis / Master of Social Work (MSW)

Appropriate housing for the aging American population is a timely topic of research in both housing and gerontology. Universal design is an innovation in housing design that is gaining interest from both industries. This research examines the effectiveness of universal design features that have been identified by experts in the field of aging, housing, and universal design as important to resident and caregiver participants of the ECHO demonstration housing program. A national survey was conducted that included all available current residents of the HUD ECHO houses and their caregivers. The relationships between age, effectiveness of universal design features, health and dependency were investigated. Quantitative results include some confounding relationships, and plausible explanations. A qualitative analysis, based on on-site and telephone interviews, and tape recordings of those interviews with residents and their caregivers, as well as architectural drawings, observation, and photographs of the ECHO houses provided additional details. The qualitative approach indicated that many of the universal design features recommended by the experts consulted satisfactorily met the needs of residents and/or their caregivers. It also revealed, however that some features were not considered important by residents and caregivers, some were not reported as present (when they were documented by the researcher as present), and at least one HUD-specified universal design feature was not provided by ECHO houses. Another aspect of the qualitative perspective addressed the health of the residents. Health characteristics are presented in the context of their effect on dependency. Phase II dependency task information was compared to that reported in phase I, and improvement and decline was noted. Conclusions, and Implications that elaborate on findings, and future research is recommended for taking this research to the next level. / Ph. D.

Bakgrund: Individer med neuropsykiatriska funktionsnedsättningar är en relativt ny målgrupp, vilket gör det angeläget att undersöka hur de bäst får stöd. Gruppboende och boendestöd är två vanliga stödformer för denna målgrupp. I de lagstiftningar vilka stödformerna befinner sig, kan delaktighet skönjas som ett betydelsefullt begrepp. Att påbörja någon form av stöd kan innebära en stor förändring, det är därför viktigt att uppmärksamma hur detta kan göras på ett bra sätt. Syfte: Studiens syfte har varit att med utgångspunkt hos personal, undersöka och analysera hur insatsen planeras och genomförs i praktiken när en individ med neuropsykiatrisk funktionsnedsättning flyttar till gruppboende eller påbörjar boendestöd. Vidare att undersöka och analysera personals medvetenhet om att skapa förutsättningar för dessa individers delaktighet i insatsens inledande skede, samt vilka utmaningar som finns i det arbetet. Metod: Studien har haft en kvalitativ ansats. Datainsamlingen har skett genom fokusgruppsintervjuer, med tre personalgrupper som arbetar med boendestöd eller på gruppboende. Materialet har analyserats dels genom en empirikopplad analys. Dels genom en teorikopplad analys, där en teori om begreppet delaktighet har använts. Resultat: Resultatet visar att processen när målgruppen flyttar till gruppboende eller påbörjar boendestöd i de flesta fall utgår ifrån en planering. Där den relation som byggs upp mellan individen och personalen är avgörande för hur stödet ska bli. Resultatet visar också att begreppet delaktighet är en betydande del i personalgruppernas arbete med målgruppen. Delaktighet framträder genom analysen på flera olika sätt, men främst genom att individernas självbestämmande betonas. Det är av stor vikt att starten och planeringen av insatsen utgår ifrån vad individen själv vill. Vidare syns också att personalen genom sitt agerande kan ge olika förutsättningar för delaktighet. Utmaningar i det delaktighetsfrämjande arbetet i insatsernas inledande skede kan skönjas främst genom hinder omgivningen skapar för delaktighet men också genom hinder i organisationen.

Through the design of supportive housing for adolescent mothers and their children, this practicum project explores the existing issue of teen parenting, and the importance of a supportive environment for teen mothers. Key areas of supportive design examined in the literature review include sense of control, social support, and positive distractions. This practicum also examines the developmental and environmental needs of infants. The comprehensive literature review of the existing challenges adolescent mothers face, the Theory of Supportive Design, and child development has informed the proposed design of House 784. / February 2017

Background: An essential component of managing the health care system effectively as the population ages is to provide care to seniors in the care setting that can best meet their needs. The majority of seniors wish to remain at home, to maintain their independence. Informal caregivers (family, friends and neighbours) provide as much as 80% of care to seniors who reside at home. The absence of or loss of an informal caregiver and/or a decline in a senior’s health may necessitate a change in care setting. Supportive Housing (SH) is a rapidly emerging alternative care setting for seniors who can no longer have their needs met at home. Objective: The objectives of this dissertation were: to provide a comprehensive description of the profile of SH clients in Ontario; to determining the role of SH in the continuum of care; to develop an algorithm to support care placement decisions; and to explore the longitudinal outcomes of SH clients including quality of life, and long-term care placement. The following four research questions were addressed: What are the socio-demographic and clinical characteristics of persons currently residing in SH units in Ontario? How do the profiles of current SH clients differ from the profiles of persons residing in other care settings? What changes occur in the appropriateness of SH to meet care needs over time? What factors are associated with discharge from SH to a long-term-care facility (LTC)? Methodology: The research questions were answered primarily using two Ontario interRAI data sets: A pilot sample of 1,720 SH clients collected using the interRAI Community Health Assessment and a sample of 29,790 Community Care Access Centre (CCAC) clients collected as part of normal clinical practice from clients residing in residential care setting, including SH. Data from LTC (N=832) and complex continuing care (CCC; N=425) clients in the Mississauga-Halton (MH) LHIN were also used. Data on care placement decisions were collected using a Staff Rating Form (N=332 in SH). Results: SH clients are a relatively light-care population who require support with instrumental activities of daily living (IADLs) and tend to lack an informal caregiver. SH clients who receive care from a CCAC are in the minority but represent a much more clinically complex sub-population. According to staff members, the majority (80%) of SH clients are appropriately placed; of the remaining 20%, 17% were prematurely admitted to SH and would be best cared for at home, a further 3% require LTC placement. Moreover, about 10% of seniors who receive care in the MH LHIN, have been inappropriately placed and would be best cared for in a SH unit. A Decisions Support Algorithm for SH (DASH) was developed to inform care placement decisions in Ontario. The algorithm was based on both resource availability and client care needs. Level of impairment in: IADLs, cognition, continence and score on the MAPLe algorithm (an interRAI prioritization algorithm; see Figure 11), were found to be significant predictors of care placement. Poor QoL was relatively rare (~5%) among SH clients and regression analysis was used to determine the variables associated with a decline in QoL. Finally, survival analysis determined that 20% of SH clients are discharged to LTC within one year. Age, dependence on others to perform IADLs, bladder incontinence, cognitive impairment, and higher MAPLe scores were associated with this discharge. Conclusions: Analyses in this dissertation have clearly indicated the need for a standardized assessment instrument in this sector. Arbitrary decisions around eligibility and discharge criteria for supportive housing have led to inappropriate placement of clients and confusion over the role supportive housing is to play in the continuum of care. Evidence-informed care placement decisions should consider client care needs as well as both the availability of formal and informal support. An integrated health information system, such as the interRAI instruments, facilitates a culture of evidence and improves communication across the care continuum. SH is a rapidly emerging alternative care setting for seniors. If managed carefully, SH has the potential to help address many health system level concerns as the population ages. It is hoped that this dissertation has answered some key questions and also inspired further research into an important and growing field.

Background: An essential component of managing the health care system effectively as the population ages is to provide care to seniors in the care setting that can best meet their needs. The majority of seniors wish to remain at home, to maintain their independence. Informal caregivers (family, friends and neighbours) provide as much as 80% of care to seniors who reside at home. The absence of or loss of an informal caregiver and/or a decline in a senior’s health may necessitate a change in care setting. Supportive Housing (SH) is a rapidly emerging alternative care setting for seniors who can no longer have their needs met at home. Objective: The objectives of this dissertation were: to provide a comprehensive description of the profile of SH clients in Ontario; to determining the role of SH in the continuum of care; to develop an algorithm to support care placement decisions; and to explore the longitudinal outcomes of SH clients including quality of life, and long-term care placement. The following four research questions were addressed: What are the socio-demographic and clinical characteristics of persons currently residing in SH units in Ontario? How do the profiles of current SH clients differ from the profiles of persons residing in other care settings? What changes occur in the appropriateness of SH to meet care needs over time? What factors are associated with discharge from SH to a long-term-care facility (LTC)? Methodology: The research questions were answered primarily using two Ontario interRAI data sets: A pilot sample of 1,720 SH clients collected using the interRAI Community Health Assessment and a sample of 29,790 Community Care Access Centre (CCAC) clients collected as part of normal clinical practice from clients residing in residential care setting, including SH. Data from LTC (N=832) and complex continuing care (CCC; N=425) clients in the Mississauga-Halton (MH) LHIN were also used. Data on care placement decisions were collected using a Staff Rating Form (N=332 in SH). Results: SH clients are a relatively light-care population who require support with instrumental activities of daily living (IADLs) and tend to lack an informal caregiver. SH clients who receive care from a CCAC are in the minority but represent a much more clinically complex sub-population. According to staff members, the majority (80%) of SH clients are appropriately placed; of the remaining 20%, 17% were prematurely admitted to SH and would be best cared for at home, a further 3% require LTC placement. Moreover, about 10% of seniors who receive care in the MH LHIN, have been inappropriately placed and would be best cared for in a SH unit. A Decisions Support Algorithm for SH (DASH) was developed to inform care placement decisions in Ontario. The algorithm was based on both resource availability and client care needs. Level of impairment in: IADLs, cognition, continence and score on the MAPLe algorithm (an interRAI prioritization algorithm; see Figure 11), were found to be significant predictors of care placement. Poor QoL was relatively rare (~5%) among SH clients and regression analysis was used to determine the variables associated with a decline in QoL. Finally, survival analysis determined that 20% of SH clients are discharged to LTC within one year. Age, dependence on others to perform IADLs, bladder incontinence, cognitive impairment, and higher MAPLe scores were associated with this discharge. Conclusions: Analyses in this dissertation have clearly indicated the need for a standardized assessment instrument in this sector. Arbitrary decisions around eligibility and discharge criteria for supportive housing have led to inappropriate placement of clients and confusion over the role supportive housing is to play in the continuum of care. Evidence-informed care placement decisions should consider client care needs as well as both the availability of formal and informal support. An integrated health information system, such as the interRAI instruments, facilitates a culture of evidence and improves communication across the care continuum. SH is a rapidly emerging alternative care setting for seniors. If managed carefully, SH has the potential to help address many health system level concerns as the population ages. It is hoped that this dissertation has answered some key questions and also inspired further research into an important and growing field.

Bakgrund: Många personer med psykisk funktionsnedsättning har en upplevelse av låg livskvalitet. De har också en sämre utgångspunkt materiellt, ekonomiskt, socialt och hälsomässigt. Att beviljas insatsen särskilt boende innebär att få stöd, service och omsorg i sin vardagstillvaro. Tidigare studier har visat att för att ett stöd ska upplevas stödjande behöver personalen ha både kunskap och vissa egenskaper, lyssnande, medkännande och lyhördhet. Syfte: Att beskriva vårdpersonals erfarenheter och tankar kring hur man utformar vardagligt stöd till livskvalitet för personer som bor i särskilt boende. Metod: Halvstrukturerade intervjuer gjordes där sammantaget tio personal deltog från fem särskilda boenden. Som analysmetod användes kvalitativ innehållsanalys med induktiv ansats. Resultat: Personalens erfarenheter av att ge stöd till livskvalitet rörde sig inom tre olika områden. Hur dessa områden, vårdrelation, organisation och miljö var beskaffade och upplevdes påverkade stödets insats och kvalitet. Det framkom att en viktig komponent i det vardagliga stödet utgjordes av ett omfattande motivationsarbete. Det fanns en bristande överensstämmelse mellan de boendes uppfattning om stöd behov och det som personalen ansåg att de behövde. Ett samband som visade sig var personalens uttryckta maktlöshet i vissa stödjande situationer och samtidig frånvaro eller bristande kontinuitet av handledning. Diskussion: Det särskilda boendet har som konstruktion stora utmaningar i att göra anspråk på att vara ett hem och inte en institution. Redan språkbruket etiketterar; man bor inte i en lägenhet utan på ett gruppboende och man är inte hyresgäst utan boende. De yttre strukturerna kan förstärka ett vi och dom tänkande där behov och svårigheter riskerar att bli beskrivna utifrån grupptillhörighet. / Background: Many people with psychiatric disabilities have a perception of low quality of life. They also have lower standard, materially, economically, socially and health-wise. To be granted supportive housing means getting daily support, service and care. Previous studies have shown that the supporting staff have to be knowledgeable and have special features, compassionate, responsive and attentive. Aim: To describe a health care professional experiences and thoughts on how to style casual support to the quality of life for people living in sheltered housing. Methods: Semi-structured interviews were conducted as with ten staff members from five supportive housing. The method of analysis was qualitative content analysis with an inductive approach. Results: The staffs’ experiences of providing support for quality of life was categorized into three different areas. How these areas, care relationship, organization and environment was constituted and perceived made impact on support effort and quality. It emerged that a key component of the everyday support consisted of a comprehensive motivational work. There was a mismatch between the residents' perception of support needs and what the staff felt that they needed. A relationship that turned out was the staff expressed powerlessness in some supportive situations and the absence or lack of continuity of supervision. Discussions: Supportive housing has as major challenges in claiming to be a home and not an institution. The language used; you do not live in your own apartment, but in a group home and you are not a tenant, but a person living there. The outer structures can reinforce an “us” and “them” thinking where the needs and difficulties might be described on the basis of group membership.

While researchers have identified the Housing First model of putting homeless persons into permanent housing as the best means of improving the quality of life for chronically homeless individuals, few studies have examined the perceptions of shelter staff workers on the barriers the homeless face in obtaining and maintaining long-term housing. This case study of 2 homeless shelters in New Jersey examined the relationship that fair and just democratic processes play in supporting or undermining Housing First. Data came from New Jersey's annual Point in Time counts of the number of homeless individuals and families and the causes and service needs of the homeless. Government reports were also analyzed, as well as from semi-structured interviews and focus group interviews with a purposive sample of 14 homeless shelter staff workers. The polarities of democracy model as described by Benet helped identify whether democracy was being served rightly and justly within these homeless communities. Information was analyzed by inductive coding and by identifying themes and patterns that emerged from the interviews. The primary finding of this study was that lack of available housing, lack of resources to gain access to housing, and lack of knowledge of resources that are available for housing acquisition and maintenance plays a role in causing individuals to become and remain chronically homeless. Social change implications include policy recommendations to local, state, and federal legislators to increase accountability in the allocation of funding for housing support and the development of a volunteer case management force to meet the service needs of the chronically homeless.