Health and Social Care in the Community (2015) 23(6), 632–641

doi: 10.1111/hsc.12187

Canadian community mental health workers’ perceived priorities for supportive housing services in northern and rural contexts Karen McCauley RSW PhD1, Phyllis Montgomery and Patricia Bailey RN PhD2

RN PhD

2

, Sharolyn Mossey

RN MScN

2

1

School of Social Work, Laurentian University, Sudbury, Ontario, Canada and 2School of Nursing, Laurentian University, Sudbury, Ontario, Canada

Accepted for publication 15 October 2014

Correspondence Karen McCauley School of Social Work Laurentian University Ramsey Lake Road, Sudbury, Ontario, Canada P3E 1H9 E-mail: [email protected]

What is known about this topic

• • •

People with mental health problems experience a greater likelihood of homelessness or inadequate housing. Adequate, secure housing is increasingly recognised as a determinant of health. Many jurisdictions in Canada, and internationally, do not have adequate capacity to meet the demand for supportive housing services.

What this paper adds

•

•

•

This study explored the distinct housing and supportive services challenges defined by community mental health workers in northern and rural locations in Ontario, Canada. Q methodology was used to develop four discrete viewpoints on priorities for delivery of supportive housing services from workers’ perspectives. The findings can inform the development of housing policy in similar regions of low population density.

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Abstract A relationship between mental health and supportive housing has been established, yet there exist enduring challenges in meeting the supportive housing needs of people with severe mental health problems. Furthermore, not all stakeholder viewpoints of supportive housing services are well documented in the research literature, and research has tended to focus on supportive housing provision in large, urban centres. Potentially, distinct challenges and opportunities associated with the provision of supportive housing services in smaller urban and rural communities that define the greater geographical terrain of Canada and other jurisdictions are less developed. This study describes community mental health service workers’ priorities for supportive housing services. Using Q methodology, 39 statements about supportive housing services, developed from a mixed-methods parent study, were sorted by 58 service providers working in four communities in northern Ontario, Canada. Data used in this study were collected in 2010. Q analysis was used to identify correlations between service workers who held similar and different viewpoints concerning service priorities. The results yielded four discrete viewpoints about priorities for delivery of supportive housing services including: a functional system, service efficiency, individualised services and promotion of social inclusion. Common across these viewpoints was the need for concrete deliverables inclusive of financial supports and timely access to adequate housing. These findings have the potential to inform the development of housing policy in regions of low population density which address both system and individual variables. Keywords: advocacy, human services, inclusion, mental health, policy, supportive housing

Introduction Housing, as an established determinant of health, necessitates consideration for all, and in particular vulnerable populations. The Mental Health Commission of Canada (2013) undertook a multi-year Housing First trial study. Their findings indicate that people provided with secure housing and ‘wrap around’ services, as opposed to treatment followed by housing, experienced ‘unprecedented’ improvements in their quality of life in terms of community functioning, recovery from acute symptoms of mental health problems or addiction, and employment (Goering et al. 2014). These results support the growing understanding that housing persons with enduring mental health problems needs to be recognised as a priority within the purview of both health and social welfare policy sectors © 2015 John Wiley & Sons Ltd

Canadian community mental health workers’ perceived priorities

(Carling 1995, Bond et al. 2004, Shapcott 2009, Kirsh et al. 2011, Kloos & Townley 2011, Mental Health Commission of Canada 2012). Several international reviews of housing and support service studies have been published from various stakeholder perspectives, including consumers of services, family members and to a lesser extent, service workers (Ogilvie 1997, Parkinson et al. 1999, Newman 2001, Fakhoury et al. 2002, Rog 2004, Chilvers et al. 2006, Nelson et al. 2007, Kyle & Dunn 2008). Overall, these reviewers acknowledge the challenge of generating substantiated conclusions based on theoretical and methodological differences across the included studies. Despite this limitation, these reviewers concur that housing and support services contribute positive personal and community outcomes such as increased housing tenure and decreased inpatient service demands. Canadian researchers Kirkpatrick and Byrne (2011) describe perceptions of previously homeless tenants and staff involved in a programme that provides safe, secure and affordable housing. In addition, this programme offers a range of supports including access to healthcare for physical and psychiatric illnesses. Overall, participants detail the empowering aspects of the programme. In particular, the provision of supportive living spaces was found to allow for privacy, a sense of control over one’s life, and were identified as a resource for beginning to build a new life. Empowerment is also engendered through a shared commitment to humane and dignified interactions, and the opportunity for social activities. Kirkpatrick and Byrne (2011) describe that this supportive housing programme embraces a value-based approach to promote community integration through individualised supports. In another recent Canadian study, community mental health service providers describe the challenge of orchestrating individuals’ needs with type and quality of housing and supports to promote recovery (Kirsh et al. 2011). Appropriately housing persons with mental health problems are efforts to co-ordinate comprehensive service delivery, community integration strategies, and health and welfare policy. Multiple confounding variables challenge these efforts, including variable individual needs for housing and support services; the range of diverse stakeholders, including tenants, housing providers, human services workers, family and other personal supports; the general public and the variant service offerings within temporal and geographical contexts. Barriers to housing this vulnerable population include service inaccessibility and fragmentation, unavailable tangible and intangible © 2015 John Wiley & Sons Ltd

resources, and lack of housing options (Stergiopoulos et al. 2010, Forchuk et al. 2011, 2013). In response, there is a recognised need for health and social welfare stakeholders to attend to the dynamic interplay among political, socioeconomic, cultural and geographical features of service communities (Nelson 2006, Satyanarayana et al. 2009, Mental Health Commission of Canada 2012). Appreciating that one size does not fit all (Clark & Rich 2003, Leff et al. 2009), there is a need to coalesce and mobilise human, fiscal and physical resources to enhance the success of flexible housing and support systems. It has been identified that such an endeavour may be particularly challenging in small and northern communities in Canada given the dearth of resources (Bruce 2006, Davis 2006). Despite dedicated efforts to build sustainable health and social infrastructure within small communities, equitable and timely access to appropriate housing and support resources by persons with enduring mental health challenges may be elusive (Montgomery et al. 2012). Sylvestre et al. (2007) advocate for local planning that involves the creation of distributed housing and support teams to meet the overall health needs of a local population, consistent with a broader regional plan. Within existent and emergent service structures, community mental health workers interface directly with community members who seek their services. As such, they are uniquely positioned to reveal their understanding of the challenges and opportunities associated with housing and supporting persons with mental health problems. There is little research to date, however, that represents the voices of community health and housing workers regarding the effective planning and delivery of housing and support programmes. Even less is known from the perspective of these workers within northern and rural contexts. A failure to acknowledge the views of these key stakeholders poses the risk of generating oversimplified understandings of issues experienced within a community of practice (Walter & Hyde 2012). To address this knowledge gap, the purpose of this paper was to describe community mental health workers’ perceived priorities for housing and support services within a northern and rural context. These study findings have the potential to inform practice and the development of policy in regions of low population density across Canada and in other countries. This study was part of a larger 2-year, mixed-methods, participatory action study examining multiple stakeholder experiences of housing and support services for persons with mental health problems in northern and rural communities. This paper reports 633

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exclusively on the perspectives of supportive housing service workers to showcase the unique subjectivity of this essential stakeholder group. Within the larger study, the perspective of service users, as the other key stakeholder group, is being addressed.

Methods Design The design of this study is Q methodology, an approach aimed at operationalising subjectivity within a group of participants relative to a shared topic of interest or expertise (McKeown & Thomas 1988, Brown 2008). It is a popular design used in multiple disciplines as it blends quantitative and qualitative elements for investigating participants’ perceptions, attitudes and opinions. Q methodology’s feature of allowing for the integration of multiple perspectives is particularly suitable for yielding a theoretical rendering of complex and debated issues (Watts & Stenner 2005). This study, a component of the larger study, was ethically approved by academic and participating community agencies. Setting and sample Canada does not have a national social housing policy. As such, the quantity and quality of social housing stock varies across and within provincial jurisdictions. In Ontario, much of the existing social housing infrastructure is ageing and deteriorating, and the development of new social housing stock has not kept pace with demand (Medow et al. 2013). This circumstance is particularly relevant to smaller urban and rural communities (Bruce 2006), which defines the study’s four urban centres and their peripheral rural communities. The population size of the four urban centres ranged from 43,165 to 160,376, distributed across a geographical region of over 7800 square kilometres (Statistics Canada 2011). Given the status of provincial housing policy, the four communities offer a variety of housing and support services for persons with mental health problems in partnership across a primarily non-profit service sector that relies heavily upon government funding. In northern community practice and Canadian policy literature, supportive housing is a term used inter-changeably with supported housing to refer to a spectrum of residential living circumstances ranging from segregated living with comprehensive personal care supports to independent rent-geared-to-income housing with access to voluntary daily living and supports (Nelson 2010). For the purposes of this 634

study, supportive housing refers to independent residential housing accessed through local mental health workers. Service workers employed by such agencies offer a range of supports such as informational, employment counselling and advocacy to help service users maintain tenancy and well-being. During the early stages of the larger study, contact was made with the Canadian Mental Health Association within each of the study communities. This contact generated a list of local partner agencies involved in the delivery of support and housing services for persons with mental health problems. From this list, service providers were sent an invitation to attend a half-day structured forum hosted in their community. Participants for this study were recruited at each of these four community forums focusing on knowledge translation activities for community-specific preliminary findings from the larger study. The total number of registrants was 61, including community workers and administrators from hospital and community mental health services; child and family services; legal services; peer support; emergency, violence and long-stay shelters; supported and public housing; and city council. A sample between 40 and 60 participants is considered optimal in Q methodology (Dziopa & Ahern 2011). Inclusion criteria were self-identification as a community provider of either health or social services to persons diagnosed with mental health issues, and willingness to provide informed consent. Participants were not excluded based on age, gender, culture, role preparation, formal education, professional affiliation or years of experience in servicing individuals with mental health problems. Data collection The community forums were facilitated in 2010 to inform research participants about the major findings and themes from the interview gathered over the course of the larger parent project. The 39 Q statement cards were defined from a content analysis of this data and the dominant themes that emerged from the larger sample of a minimum of four semistructured focus groups interviews with supportive housing stakeholders, including supportive housing tenants, and workers at different levels of service delivery system, within the participating communities. At each of the community forums, there was the opportunity for all those in attendance to engage in an individual Q sorting activity and group discussion that involved formulating and sharing their perspectives about housing and support service priorities particular to their community. At the beginning of each forum, attendees were provided with study © 2015 John Wiley & Sons Ltd

Canadian community mental health workers’ perceived priorities

information by the researchers. In addition, they received a study package containing a pencil, information letter, consent form, a set of 39 Q statement cards and a blank Q template. They were also informed that participation in the forum activities was not dependent upon agreement to participate in the study. Q sorting is a strategy used to explore interactions and perceptions of interest in health research. It involves individuals ranking a set of statements that represent a topic of interest (McKeown & Thomas 1988, Brown 2008). The 39 statements about priorities for planning and implementing supportive housing services in this study were generated from a preliminary thematic analysis of focus group data from the larger study. The Q template contained 39 spaces arranged as an inverted pyramid. The base of the pyramid was a 9-point Likert scale, from least important ( 4) on the left to most important (+4) on the right. The question above the Likert scale was, ‘What are the health and social priorities for persons living with mental health and housing challenges in your community?’ To respond to this question, attendees read each of the 39 statements, and initially sorted them into three piles, least important, neutral and most important. Next, they selected a statement from their most important pile, considered to be the highest priority, and placed it in the far right column (+4) on the Q template. Then, attendees were directed to undertake the same process for the statement in their least important pile, placing in the far left column ( 4) on the Q template. All cards were then sorted, alternating between their most important and least important piles, ending the process with cards in their neutral pile. When finished, attendees were asked to review their sorting one last time to ensure that their views accurately represented their perspectives about supportive housing service priorities. This 30-minute activity was followed by a group discussion on individual rankings and rationale for prioritising statements. At the end of the discussion, attendees had the option to submit a signed consent and their Q templates for formal analysis. Upon signing the consent, attendees became study participants. Socio-demographic information was not collected to preserve participants’ anonymity, especially in the two small rural communities. Data analysis Each attendee-completed Q sort was inputted into the formally accessible, specifically dedicated Q methodology PQMethod program, version 2.11 (Schmolck 2002). The updated PQMethod version 2.35 is now © 2015 John Wiley & Sons Ltd

available (Schmolck 2014). The programme’s product is described as a participant-generated configuration of statistically significant inter-correlated statements representing shared viewpoints designated as unique factors (Watts & Stenner 2005, Stenner et al. 2008). In contrast to standard R methodology, the participants were regarded as the variables; the statements were the cases (Brown 1993, Stenner et al. 2008). The process of interpreting the cluster of statements composing a viewpoint began with the programme producing a correlation matrix of all Q sorts. The matrix showed a by-participant comparison of rankings across the total number of 39 statements. Then, the matrix underwent centroid factor analysis to determine the number of different Q sorts present within a factor. That is, highly correlated Q sorts within a factor shared a ‘family resemblance’ or a particular ‘qualitative viewpoint’ making them distinct from other families (Brown 1993). These initial factors were then subject to varimax rotation to determine the extent to which a participant’s Q sort contributed to the emergent factor structure (Watts & Stenner 2005). The programme generated factor scores for each statement, estimates that modelled the ranking pattern of participants who loaded significantly on any given factor. Participants’ Q sorts that did not load significantly on any factor were excluded from further analysis to maximise the difference between factors (McKeown & Thomas 1988). The resultant factor scores were arranged in multiple separate factor arrays; a ‘synthetic’ composite of particular groupings of participants with shared subjectivity (Stenner et al. 2008) about supportive housing services. Then, the researchers selected the most suitable array from which to continue the analysis process. In this study, the number of factors per array ranged from two to seven. Some of these arrays were not considered suitable given that they did not contain distinguishing statements with at least a +4 or a 4 ranking. Others were not theoretically informative. The selected factor array contained four distinct factors and one consensus factor which was deemed most appropriate in explicating the attendees’ pointsof-view supported by the post-Q sort discussion. It explained 44% of the variance. To assist with interpreting the viewpoint within each of these factors, the output displayed the rank and Z-score for each of its distinguishing statements (Tables 1–4). From this generated Q sort model, theoretical interpretation of the set of statements representing a viewpoint was undertaken by members of the research team individually. Upon agreement of all team members, a label was assigned to the viewpoint descriptive of a housing and support priority. 635

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Table 1 Functional system Statements Accessible workers who can provide individualised personal support Progressive policy that sets and enforces minimal housing standards Responsible landlords Access to a range of addiction services Proactive policy initiatives ensuring accountability of service providers Support in navigating between healthcare and social service systems Work/education/life skills opportunities close to housing Opportunities to nurture hope, self-esteem and independence Support and housing services close to housing Services and supports to mitigate feelings of social isolation and stigma Relations with neighbours Opportunities for consumers to actively participate in the wider community Being surrounded by items that have personal meaning Access to nature/outdoors

Ranking

Z-score

3

1.10*

3

1.10*

Viewpoint 1 – functional system

2 1 0

1.09 0.52 0.09*

0

0.04

0

0.01*

0

0.00

1

0.41*

1

0.50*

2 3

0.88 0.12*

3

1.62*

4

1.79*

This first viewpoint (Table 1) was held by 18 service workers. They identified that the operationalisation of support and housing services was the greatest priority in northern and rural contexts. Accessible, flexible service workers as well as responsive and enforceable policy pertaining to housing standards were endorsed as key features of a functional system. Collectively, this group of service workers identified the system’s responsibility to ensure the rights of consumers to suitable accommodations and access to individualised formal supports. Suitability was defined as accommodations in accordance with minimal housing standards regulated by designated local housing authorities and relevant provincial housing policy. ‘Responsible landlords’ who uphold legislated housing standards were perceived to be essential members of a functional system. Within their conceptualisation of a functional system, least priority was placed on social opportunities, personal possessions and connectedness to the natural environment in servicing individuals with mental health problems.

*P < 0.01.

The reliability and validity of Q methodology has been verified in multiple studies (Watts & Stenner 2005, Brown 2008).

Results Of the 61 service providers attending the forums, 58 (95%) gave written consent for inclusion of their completed templates in this study. Of these, 45 loaded significantly (P < 0.05) on one of the four discrete viewpoints. As mentioned above, the Q sorts of 13 remaining service workers were not included in the results. There was no defining attribute to assign to those whose data were not loaded on one of the four discrete viewpoints. Included participants ranged from senior administrators to community workers who provide direct service to people with mental health problems who experience homelessness, housing insecurity or housing that was not adequate to meet personal need. In the multidisciplinary service context of this study, the assigned labels were inclusive of the content that comprised each viewpoint while avoiding any disciplinary-specific connotations that may be associated with more descriptive, disciplinary-specific vocabulary. 636

The four discrete viewpoints were functional system, service efficiency, individualising services and promoting social inclusion. The consensus viewpoint was labelled concrete deliverables.

Viewpoint 2 – service efficiency The priority rankings of five service workers exemplified the second viewpoint entitled service efficiency (Table 2). They perceived that it was most important to guide individuals with mental health problems to services within health and social systems to fulfil their immediate needs. This group also perceived that prioritising service provision minimises the risk of an individual’s social exclusion. Congruent with this perception was the high priority attributed to the provision of a range of readily accessible services within a welcoming environment. Service efficiency was predicated upon communication between individuals and appropriately prepared service workers competent in effectively mobilising resources. Lesser priority was attributed to the quality of the individuals’ home environment. Viewpoint 3 – individualising services Nine service workers held the third viewpoint labelled individualising services (Table 3). Within this viewpoint, knowing the individuals’ needs was most © 2015 John Wiley & Sons Ltd

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Table 2 Service efficiency Statements Accessible workers who can provide individualised personal support Services and supports to mitigate feelings of social isolation and stigma Access to a range of supports in a timely manner A user-friendly system Being able to navigate the mental health system to access services Secure/stable housing Support and housing services close to housing Increased training and resources for service providers Safe housing Being surrounded by items that have personal meaning Well-maintained housing Responsible landlords Access to nature/outdoors Relations with neighbours Environmental issues (temperature, running water, mould)

Table 4 Promoting social inclusion Ranking

Z-score

4

1.81*

3

1.43*

3

1.30*

3 2

1.14* 0.87*

1 1

0.79* 0.78*

1

0.61*

0 1

0.23* 0.59*

2 2 2 3 4

0.83* 0.87* 1.22 1.46 1.69*

Table 3 Individualising services

Accessible workers who can provide individualised personal support Support in navigating between healthcare and social service systems Access to nature/outdoors Being able to have pets Support with their housing maintenance Environmental issues (temperature, running water, mould) Relations with neighbours Opportunity for participation in family life (immediate and extended) Progressive policy that sets and enforces minimal housing standards Reduced caseloads for service providers A user-friendly system Support and housing services close to housing Work/education/life skills opportunities close to housing

Ranking

Z-score

Z-score

3 2

1.53* 0.95*

1 1

0.60* 0.40*

0

0.25

1 1 2

0.47 0.64 0.89*

2

1.06*

2 3

1.07* 1.39*

3

1.45*

4

1.99*

an individual’s life circumstances, such as informal relations within their home environment. If services are individualised and appropriately navigated by an accessible worker, proximity to services and the complexity of the system are of lesser importance.

1

0.51

1

0.46

Viewpoint 4 – promoting social inclusion

1 0 0 0

0.36* 0.21* 0.21* 0.00*

0 0

0.03 0.08

2

0.92

3 3 4

1.04* 1.51* 1.67*

4

1.70*

The fourth viewpoint, labelled promoting social inclusion, was held by 13 service workers. Beyond the provision of basic human needs, these service workers identified the importance of ensuring that individuals had opportunities for involvement (Table 4). These service workers prioritised engagement with friends and family as a pathway to developing belongingness outside services. Building intimate social relationships and participation in fulfilling leisure activities, with the assistance of enhanced financial benefits, offered the possibility of meeting higher order human needs. As such, this viewpoint emphasises the need for individuals to build their lives surrounded by informal supports. The three lowest ranked statements within this viewpoint pertained to addressing the needs more specific to service workers and family caregivers.

*P < 0.01.

highly ranked. Service workers are poised to maximise need fulfilment through partnering and sharing responsibility for assembling a network of resources to establish individualised services. The zero ranking of five statements indicated that service providers perceived a neutral role in addressing the quality of © 2015 John Wiley & Sons Ltd

Friendships Opportunities to pursue hobbies nd personal interests Enhanced social assistance benefits Opportunity for participation in family life (immediate and extended) Support and housing services close to housing Relations with neighbours Access to nature/outdoors Effective service co-ordination between agencies Support in navigating between healthcare and social service systems Being able to have pets Concrete strategies for support and housing to lessen stress for ageing family caregivers Increased training and resources for service providers Reduced caseloads for service providers

Ranking

*P < 0.01.

*P < 0.01.

Statements

Statements

Consensus viewpoint – concrete deliverables Concrete deliverables was comprised of two similarly ranked statements across the four discrete viewpoints. 637

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Access to adequate income to support basic cost of living such as utilities was a high priority. In addition, all service providers considered timely access to a range of housing services as important.

Discussion The relationship between housing and mental health is well established in the research literature. There is evidence that establishment of housing to support mental health is mobilised through the provision of supportive housing assistance (Nelson et al. 2007). Service workers are key stakeholders in the day-today delivery of such services and, as such, hold insider information regarding service strengths, weaknesses and priorities for improvement. This study provided an opportunity for service providers to prioritise housing and support services needs within their specific northern and rural practice context. The resultant four discrete viewpoints about priorities reaffirm the established understanding that provision of quality supportive housing services is a complex and multidimensional process encompassing both systemic and individualist issues. In combination, these articulated perspectives call for a functional system that allows for the efficacious provision of individualised services that ultimately house individuals within a context that allows for growth and facilitates social inclusion. As noted in the consensus perspective, there is an urgent need for adequate economic resources and timely access to a range of housing services. Similarly, Kidd et al. (2013) reported the fundamental need for pragmatic resources such as adequate housing stock and funding to mitigate individual risks and address the unique needs of individuals with serious mental health problems. To realise a functional system, service workers must demonstrate role competency within a structure that upholds sound housing policy. In Ontario, housing standards are legislated primarily through the Housing Services Act (Government of Ontario 2011). This Act designates the parameters of local housing services administrators’ authority to maintain supportive housing stock. However, variability in enforcement coupled with long waiting lists for regulated social housing has enabled some landlords to flout the Residential Tenancies Act (Government of Ontario 2006). In such circumstances, indicative of a dysfunctional system, vulnerable individuals are further disadvantaged by life within a sanctioned home environment that may violate legislated health and safety standards. Surrounded by a substandard environment and living while currently living with mental health problems, there is little opportunity to 638

secure safety, augment self-esteem and rebuild one’s life (Kirsh et al. 2011, Centre for Addiction and Mental Health 2012). For a functional system to be realised, it is incumbent upon stakeholders including policy makers, service workers and landlords to ensure safe, accessible housing environments, and to be accountable to tenants. A hallmark of a functional system, as articulated in this study, calls for establishing and enforcing progressive housing policy; however, from a pragmatic perspective, this is a challenging undertaking. For the last half century, in Canada, consistent calls for strategic investments in community-based supports for people with mental health problems have met with minimal tangible response (Sylvestre et al. 2007, Mental Health Commission of Canada 2013). Responsibility for social housing, in particular, has been downloaded to the provinces; and provinces have increasingly delegated administration and maintenance of existing housing stock to municipalities (Nelson 2010). This may be particularly problematic for low population density municipalities that have fewer resources to commit to supported housing. Although Ontario municipalities contribute $1.2 billion to social housing each year, this figure does not include the costs of maintaining ageing housing stock (Association of Municipalities of Ontario 2013). The construction of a functional system must be the product of negotiated policy development at different levels of government and within communities. Similarly, service efficiency, the second viewpoint of the service workers in this study, shares an emphasis on systematic issues related to supports and housing. The administration of a range of appropriate services needs to be co-ordinated to promote wellbeing. This requires efficient collaboration between stakeholders to provide seamless care (Ministry of Health and Long-Term Care 2009). Currently, in Ontario, the diagnosis of a chronic mental impairment as either illness or disability will determine what system assesses supportive housing eligibility. For example, services for individuals diagnosed with mental health problems typically fall within the purview of the Ministry of Health and Long-Term Care. Alternately, service eligibility for those with a mental disability is administered within the auspices of the Ministry of Community and Social Services. Having distinct administrative systems and housing services differentiated by presenting diagnosis compounds system inefficiency. This is particularly evident when the boundaries that distinguish illness and disability are blurred (Hudson & Chan 2002, Lewis 2006, Shakespeare 2006). Provan and Milward (2010) found that: © 2015 John Wiley & Sons Ltd

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Through co-ordination, an integrated system supposedly minimises duplication of services by multiple provider agencies, while increasing the probability that all essential services are provided somewhere in the system, and that clients will have access to these needed services. (p. 164)

To that end, in northern and rural regions, the establishment of service efficiency must bridge bureaucratic silos between health and social services ministries. Creating partnerships has the potential to reconcile inefficiencies in the allocation of resources and expertise. Doing so will optimise the success of offering the right mix of timely supports to those that need them (Ministry of Health and Long-Term Care 2011). Navigating between service structures is a complex undertaking. At an organisational level, collaboration between service providers tends to be dynamic and complicated with the following factors defining the context for interagency collaboration: environment, which includes geographical isolation and political contexts; the process or structure of the collaboration; communication patterns between members; and resources attached to the collaboration (Rattelade & Sylvestre 2012). Intentional collaboration between service structures may be particularly important in small communities, where workers must do a lot with few healthcare resources (Chipp et al. 2008). The benefactor of such efficiency is the individual with mental health problems who is not able to independently navigate between healthcare and social service systems. Individualising services is a viewpoint that advocates for a greater role for service recipients in obtaining and maintaining necessary housing services. This viewpoint aligns with a person-centred approach to support and housing services; a position identified by other researchers and policy makers to foster selfdetermination (Nelson 2010, Ministry of Health and Long-Term Care 2011, Centre for Addiction and Mental Health 2012). Similarly, Sommerseth and Dysvik (2008) suggest that the provision of quality services entails viewing the consumer as an active collaborator in decision-making about the types of housing and services required. Subjectivity in assessing support and housing needs is seen to be inevitable, and decisions are based upon the needs of the applicant. For service workers in this study, individualising services may be an expression of their concern regarding their ability to access the resources that consumers request. According to Schneider (2010), housing people with mental health problems is more than just applying the policy of the agency. Rather, workers are: © 2015 John Wiley & Sons Ltd

Constantly making sense of their clients’ problems and potential solutions to those problems, ‘operationalising’ various organisational imperatives in a moment to moment, case by case way. (p. 308)

Accessing scarce resources in keeping with agency protocols and the expressed needs of the individual is a precarious balancing act. Supportive housing workers are operating in an environment that compels them to balance the demands of service users with the finite resources available for service provision (Rattelade & Sylvestre 2012). The inability of service workers to secure the necessary resources to meet their clients’ needs may sometimes manifest itself in a sense of professional inefficacy. Increases in rent supplements may contribute to expanding housing choice as well as promoting workers’ positive contribution to individuals’ overall well-being. For service providers in this study, promoting social inclusion is associated with the importance of ensuring opportunities for individuals with mental health problems to craft a life inclusive of personal connections and interests. Social inclusion has become familiar policy rhetoric in the United Kingdom, Europe, Australia and New Zealand. In Canada, there exists no formal policy mandate on inclusion, or a government ministry devoted to realising such an objective. It is best understood as a ‘“policy current”: a guiding, fluid policy that moves across departmental boundaries’ (Carey et al. 2012, p. 50) including mental health and housing. It is inferred that policy that enhances involvement in communities-of-interest will result in supportive housing tenants needing to rely less upon formal and informal supports. To this end, individuals require increased financial resources. A functional and efficient system has the potential to generate resources for the realisation of ‘higher order’ needs such as close relationships, engagement in satisfying leisure activities and active involvement in their community (Nelson et al. 2007). Providers in this study recognised that housing does not necessarily translate into social involvement. Only after their basic needs are secured can persons with mental health problems be capable of rebuilding their lives (Forchuk et al. 2006). The findings of this study are limited by the parameters of the 39 Q statements, which may not be inclusive of all the priorities northern service providers may face in practice. The local demographics of specific communities may have contributed to undermining consensus around factors to a greater extent than if the Q sort activity were conducted exclusively in one community. At the same time, however, the findings from this study indicate a

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degree of shared perspectives among service providers across different communities. An area for further investigation is how supportive housing workers interpret relevant legislative mandates and organisational policies to determine housing eligibility for supportive housing applicants. In addition, further investigation into the specific types of housing supports that contribute to maintaining secure housing and well-being would help to further develop supportive housing services delivery in northern communities. In conclusion, northern and rural workers prioritise the need for ongoing development and maintenance of safe and accessible supportive housing stock. For a more functional system, this may entail streamlining eligibility criteria and co-ordinating bureaucracies between stakeholder ministries, investment of resources into local housing authorities and better co-ordination of services between community workers for individualised service. Efficiency involves navigating systems fraught with challenges associated with the timely provision of the right resources to meet service demands. Realisation of social inclusion is dependent upon meeting persons’ individual needs while mindful of their autonomy. In the ongoing development of more efficient and flexible supportive housing policy and service delivery systems, the expertise of supportive housing and service workers should be widely consulted.

Acknowledgements This research was funded by the Ontario Mental Health Foundation.

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