Transitioning Inpatients to Housing: A Group Discharge Approach

To the Editor: An extensive body of literature documents the benefits to individuals with severe mental illness of good-quality housing in which adequate supports are integrated. These benefits include housing stability, less hospitalization and criminal justice involvement, decreased symptomatology, reduced health care costs, and better quality of life (1). Despite this evidence base, large numbers of psychiatric patients experience protracted hospital stays. In Ontario these individuals account for 51% of inpatient long-stay days, and it has been estimated that 40% could be served in the community with appropriate support (2).

Although it is important to understand what housing models are effective in this context, implementation is the key challenge. Here we describe a strategy that has proven to be successful at the Toronto Centre for Addiction and Mental Health (CAMH), the largest psychiatric service provider in Canada. The CAMH high-support housing initiative was launched in 2009 to address the needs of a cohort of 18 clients with schizophrenia who were residing in a single inpatient unit and whose average length of stay was nine years (range five to 25 years). The cohort included seven women and 11 men ranging in age from 39 to 58 years. The project involved a partnership in which a subsidized-housing provider made available 18 units on two adjacent floors of a 12-story building. A community service organization provided 24-hour support, seven days per week. CAMH provided programming with case management, peer support, and psychiatric services.

A critical component of the success of this project was a group discharge strategy. For clients who had been institutionalized in a highly structured environment for up to 25 years, the prospect of moving to a more independent community setting was extremely anxiety provoking. Although inpatient staff were planning to assist in gradually transitioning these clients into housing, significant concerns were expressed about whether the project would be successful. We found that moving clients in small groups of four or five fostered a culture of mutual support, even though many clients did not have strong relationships while on the unit. Friendships emerged, along with a sense of shared experience that appeared to be very important in their tolerating the stress of extensive changes in their living environments and routines. Although a recovery model with individualized goals and program planning was used, this foundation of group cohesion has promoted greater comfort in taking risks as these individuals explore avenues of community participation, such as volunteering, church involvement, work, and leisure activities.

Other outcomes are equally encouraging. The per-diem costs are markedly lower than the cost of inpatient hospitalization. Further, the rate of rehospitalization has been extremely low, with only one of the 18 clients returning to hospital in the three years since the project was initiated. These preliminary findings suggest a need for further study to better understand the associations between group discharge and housing outcomes.