Generating Evidence for a Comprehensive Support Package to Stabilize Youth Trajectories Out of Homelessness: A Tertiary Prevention Strategy
Phase: NA
Conditions: Youth, Homelessness
Sponsor: Centre for Addiction and Mental Health

Generating Evidence for a Comprehensive Support Package to Stabilize Youth Trajectories out of 
Homelessness: A Tertiary Prevention Strategy - REB    Protocol Version 3.0, May 30, 2018   
  
          
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REB Protocol 
Version 3.0, May 30, 2018 
"Generating Evidence for a Comprehensive Support Package to Stabilize Youth Trajectories out of 
Homelessness: A Tertiary Prevention Strategy" 
PI: Sean Kidd, Co-PI: Christopher Mushquash, Co-I: Tyler Frederick, Co-I: Kwame McKenzie,  
Co-I: Nina Vitopoulos, Co-I: Renee Linklater, Co-I: Alexia Jaouich 
Overview 
 
This project builds upon initial proof of concept work examining the optimal set of supports for youth 
who have recently exited homelessness – an intervention comprised of mental health and peer supports 
alongside transitional case management. This collaborative model will be tested as a proof-of-concept in 
Thunder Bay with Indigenous youth and a trial will be conducted in Toronto to optimize and determine the 
effectiveness of the existing model of support. 
Background 
Homelessness and Risk Literature 
 
Child and youth homelessness is a major global problem with estimates of at least 150 million 
internationally (Unesco, 2014). It is a pervasive problem, and one not relegated to low income contexts (e.g., 1 
million – United States (Kidd & Scrimenti, 2004); 40,000 Canada (Gaetz, Donaldson, Richter et al., 2013). 
Many determinants of youth homelessness have been posited, the most prominent of which are child 
maltreatment (Karabanow, 2004; Kidd, 2006), poverty (Public Health Agency of Canada, 2006), and mental 
illness (Craig & Hodson, 1998; Karabanow, Hopkins, Kisely, et al., 2007), though the lack of longitudinal 
research greatly hampers any conclusive identification of risk weightings and interactions.  
 
Once on the streets the exposure to risks to physical and mental health are great, as evidenced by high 
mortality rates due in large part to suicide and drug overdose (Roy, Haley, & Leclerc et al., 2004; Roy, Haley, 
& Boudreau et al., 2009). Though youth may be highly creative and resilient in their survival efforts 
(Karabanow, 2008; Kidd & Davidson, 2007; Rew & Horner, 2003), the outcomes for most over time is poor. 
The response to youth homelessness has been, historically, highly variable and at a population level ineffective, 
if the steadily increasing numbers of such youth in recent decades can be taken as an indicator (Kidd & 
Scrimenti, 2004). In the last 100 years in North America, for example, frameworks for intervention have 
included eugenics, social reform, psychiatric treatment, and criminalization (Kidd, 2012). At present, dominant 
approaches are crisis response in the form of general drop-in and emergency shelter service and a criminal 
justice system response in the form of ‘safe streets’ legislation (Slesnick, Dashora, & Letcher et al., 2009). 
 
Evidence surrounding the effectiveness of these interventions is generally lacking. What little evidence 
that does exist paints an unclear and generally unpromising picture. While some specific interventions show 
promise, in general, models that are effective with other marginalized populations such as enhanced case 

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management, motivational interviewing, and housing first approaches, have not demonstrated clear benefit 
(Altena, Astrid, & Sonja et al., 2010; Slesnick, et al., 2009). 
Transition from Homelessness Literature 
 
Relative to the large body of work examining the risks associated with pathways into youth 
homelessness and the risks associated with living on the streets, very little work has concentrated on pathways 
out of homelessness. There exist some cross-sectional qualitative investigations conducted with youth 
considering or beginning to engage in the transition process. This work has highlighted the challenges 
associated with addictions, trauma, discrimination, unemployment, and breaking ties with street culture and 
street friends (Karabanow, 2008). Some other work has suggested the importance of self-concept in these 
transitions, with how youth identify with either street or mainstream contexts and cultures being important to 
their motivation to exit homelessness (Kidd & Davidson, 2007). 
 
There are also several longitudinal quantitative studies which have engaged homeless youth and tracked 
days housed for up to two years (Barber et al., 2005; Slesnick et al., 2008a;2008b; Milburn et al., 2009; 
Rosenthal et al., 2007; Tevendale et al., 2011; Roy et al,. 2014). While the methods and findings of these studies 
vary considerably, there are some consistent themes. The most consistent finding is that drug and alcohol abuse 
reduced the number of days housed (Rosenthal et al., 2007; Slesnick et al., 2008a; Tevendale et al., 2011; Roy 
et al,. 2014). Number of days housed has also shown positive associations with connections with peers and 
family (Slesnick et al., 2008b; Milburn et al., 2009), less risk behavior (Slesnick et al., 2008a), being female 
(Slesnick et al., 2008a), past and current engagement in education (Milburn et al.,2009; Roy et al., 2014), being 
younger, and having been homeless for a shorter period of time (Tevendale et al., 2011). Somewhat less 
intuitive are findings that youth who had left home involuntarily (i.e., “throwaways”) were more likely to find 
housing (Tevendale et al., 2011) as were youth experiencing mental health problems (Roy et al., 2014). 
Interpretations of these latter findings fell along the lines of the self-concept work of Kidd & Davidson (2007), 
suggesting that pathways out of homelessness depend upon how a youth positions themselves relative to home 
and street contexts. For example, emotional distress might indicate a youth who feels that they do not belong or 
fit in on the streets and possesses greater motivation to find housing.  
 
This recent longitudinal work that tracked cohorts of homeless youth has been extremely valuable in 
identifying factors that are related to trajectories out of homelessness. However, these studies have some 
shortcomings. These includevery high attrition rates and, most significantly, that self-reports of days housed is a 
narrow measure if the intent is to capture the stability of trajectories out of homeless spaces, social contexts, and 
self-concepts (Frederick et al., 2014). 
Work Directly Informing this Proposal – Understanding the Process 
 
In a recent SSHRC funded two-site study focussing on Toronto and Halifax, Kidd, Frederick, 
Karabanow and colleagues used a mixed methods longitudinal design to examine pathways out of homelessness 
across a diverse group of 51 youth (Frederick et al., 2014; Karabanow et al., 2014; Kidd et al., 2016). Unlike 
previous work, this study focussed upon youth who had recently achieved housing stability and involved an in-

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depth examination of challenges to and facilitators of stability - defined in a manner considerably broader than 
days in housing.  
 
Some aspects of the findings of this study mirrored previous work. It was found that in the one year 
period of study, most participants were not making substantial gains in achieving health and stability. Of the 51 
participants, 24% experienced a loss of stable housing over the year, and for all participants pathways were 
protracted and complex with significant challenges in securing decent quality housing, employment, and 
engagement in education. Over the year there was no significant improvement in community integration 
(including both psychological and community activity domains), mental health and quality of life declined and 
showed erratic courses, and hope declined. It was found that having a community support worker, living in a 
supported housing context, and having a hopeful perspective mitigated threats to housing stability such as a lack 
of employment and criminal justice involvement. Furthermore, it was found that the more protracted the process 
of transitioning out of homelessness, the greater the difficulty youth had in achieving a decent quality of life and 
sense of engagement in non-homeless communities, relationships, and self-concepts. Developing a sense of 
purpose and meaning was found to be essential to this process, with youth finding that housing had been 
'oversold' in terms of benefits. Many struggled greatly as they experienced social isolation, complex trauma 
symptoms, poor physical health, and other challenges.  
 
Despite these myriad challenges, there were also many successes and opportunities. Tremendous 
resilience was observed as youth persisted in the face of many challenges and stayed away from street contexts, 
addressed addictions, and engaged in a very positive way in tasks from the mundane to more complex 
navigations of employment and re-establishing relationships with family.  
 
This study, along with previous work, had several clear practice implications which were both directly 
stated by youth and supported by quantitative analyses: 
1. Having a sense of purpose, meaning, and engagement in community are important to sustaining hope and to 
avoiding a drift back into homelessness.  
2. Concrete, tailored, and ongoing information and support is needed in areas such as independent living skills, 
navigating systems of support and criminal justice.  
3. Social engagement with non-street involved people is essential to developing identity and sustaining 
motivation, but many youth have limited opportunities for finding such engagement.  
4. A substantial proportion of youth struggled with significant psychological concerns, particularly trauma, that 
impacted all domains of their life including relationships, motivation, stress management, and substance use.  
5. Most participants felt that support in these areas was difficult to access or non-existent, and many were 
reluctant to access the modest amount of support available through homeless drop-ins and shelters for fear of 
having their addictions triggered or falling back into old negative patterns.  
 

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Work Directly Informing this Proposal – Intervention Feasibility 
In response to the challenges outlined above, and with the support of a grant from the Ontario Ministry 
of Child and Youth Services, we developed and tested a tertiary prevention strategy called the Housing 
Outreach Program Collaborative (HOP-C) which launched in the summer of 2015. In this approach we focused 
on collaborations and interventions that have the greatest potential to be effective with this population. We 
brought together partners from a number of sectors in the GTA and have tested a 3-pronged set of supports 
(intervention described in detail in the methods): 
• Transitional Case Management 
• Mental Health Interventions: Group, individual, family 
• Peer Support 
This is an intensive, 6-month critical time intervention – one that jointly addresses many points of 
vulnerability (mental health crises, housing instability, justice involvement) while fostering resilience and 
connection with resources in employment, education and training domains. It is unique in both content 
comprehensiveness and integrated process of delivery. Also important was the development of a collaborative 
and responsive partnering process, to facilitate effective organizational interfaces and seamless service 
integration so participants can experience a tailored and coherent set of supports. With CAMH, the Centre for 
Mindfulness Studies, Covenant House, LOFT, and SKETCH at the service level and the Wellesley Institute 
leading evaluation, we have carefully attended to a collective impact framework. 
This initiative has proven feasible and is demonstrating good outcomes – with excellent youth 
engagement, reports of lower social isolation, improved mental health, and engagement with resources, and 
spin-off benefits of closer collaboration between organizations. We successfully met the target of youth 
engagement, with a total of 31 youth participating, minimal attrition (n=2), and we observed no indications that 
HOP-C resulted in risk of any form, both with respect to the intervention itself and the mixed methods research 
methodology. This promising feasibility work formed the foundation from which we were successful in 
obtaining a grant from the Local Poverty Reduction Fund to support the study described in this proposal.  
Current Proposal 
The next steps for this program are to test its feasibility in expanded settings and to unpack which 
elements are driving effectiveness. These steps are crucial to scale the program provincially and to break the 
cycle of homelessness that systemically wastes resources and individually erodes health, wellbeing, and 
potential. This work will: 
1. Assess how the success of the Toronto model will transplant to a smaller and less-resourced centre 
(Thunder Bay), and how it will culturally adapt to an Indigenous youth population. 
 
 

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2. Determine through a randomized trial in Toronto if the positive outcomes we are observing are due 
solely or primarily to transitional case management and if the additional peer and mental health 
components are necessary. 
Engaging in intensive, tertiary prevention shows clear promise in disrupting a cycle of poverty and 
marginalization at a critical time – if proven and scaled a key driver of chronic homelessness would be 
addressed. 
Research Questions 
 
The objective of this two-part project is to examine the effectiveness and transferability of  the Housing 
Outreach Program-Collaboration (HOP-C) transitional intervention. HOP-C has proven to be feasible with 
promising outcomes in the Toronto proof-of-concept work currently underway. The next stage is to consider 
two points of inquiry, both of which are essential if this work is to be scaled provincially. 
This study was designed to address 2 questions: 
1. Is HOP-C transferable with respect to feasibility and outcome to smaller, less resourced urban settings, 
and can it be culturally adapted for Indigenous youth?  
 
 It is hypothesized that HOP-C model will prove transferable and feasible in one such context.  
 
2. Are the benefits of the complex HOP-C intervention with all components in place greater than 
transitional case management in isolation?  
 
 It is hypothesized that the full model will provide benefit in domains of housing stability, mental 
health, and quality of life that are significantly greater than case management alone.  
We have data in hand from our recent national work in the area which provides data on 'treatment as 
usual' or the outcomes that attend typically available supports. The proposed trial will unpack benefit and be 
essential in economic and viability arguments to be made going forward.  
Methods 
Research Question 1: The Thunder Bay Site 
To address the first question, we have chosen Thunder Bay as the study site. This city is ideal for our 
evaluation because it enables a consideration of a mid-sized urban environment and is particularly relevant for 
Indigenous homeless youth, being the northern hub to which many youth from Indigenous communities 
gravitate upon becoming homeless (15). This study will focus on qualitative and quantitative indicators of 
feasibility with some probing of quantitative outcome measures. Outcome indicators are examined for the 
purposes of feasibility (if they seem to be capturing change referencing qualitative descriptions of impact) and 

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will be interpreted cautiously as this is a complex intervention with uptake of components unlikely to be 
uniform. 
Youth Participants 
The strength of this evaluation – like at our Toronto site in the original feasibility study – lies in a 
triangulation of quantitative and qualitative sources of data. Participants will be 25 formerly homeless 
individuals between the ages of 16 and 26 who have obtained secure housing in a time period up to 12 months 
previously (24 years is the age cut-off for most homeless youth services - allowing for 12 months and some 
additional leeway after exiting homeless youth services leads to an upper limit of 26 years). All participants will 
self-identify as being of Indigenous (First Nations, Inuit, Metis) heritage. Past experience with homelessness is 
operationalized as 6 or more months (not necessarily consecutive) of homelessness (no housing, in shelters, or 
transiently residing with others "couch surfing"). Secure housing refers to either supported or independent 
housing. We are proposing an upper limit of 12 months housed as our previous work (Kidd et al., 2016) 
suggests this is well within the time period in which there remains a need for support and transitions are 
tenuous, and to facilitate recruitment within the study timeframe by having an adequate pool of potential 
participants.  
The original HOP-C study findings suggest that approximately 10% attrition is to be expected. 
Accordingly, having 20-25 individuals complete the intervention would be adequate to assess feasibility 
qualitatively (Sandelowski, 1995), likely with sufficient power to assess change for the group as a whole via a 
paired sample t-test and to detect medium to large effect sizes.  
All participants will be recruited through Dilico Anishinabek Family Care (DAFC), with whom the 
CAMH Provincial System Support Program has a longstanding partnership. DAFC provides a range of 
individual, family, and community programs and services in support of Anishinabek people, and is of particular 
relevance to the hundreds of youth in Thunder Bay who are the focus of this project. DAFC has a range of 
strategic partnerships locally which will be leveraged to engage recently housed youth and will be the primary 
location from which HOP-C-North would be based. At DAFC, Assistant Director of Mental Health and 
Addictions Tina Bobinski will lead local coordination, supported in the local PI role (and clinical supervisory 
role) by Dr. Christopher Mushquash, Canada Research Chair in Indigenous Mental Health and Addiction, 
Associate Professor in the Department of Psychology at Lakehead University, and the Northern Ontario School 
of Medicine, and Clinical Psychologist at DAFC. This arm of the study will be concurrently reviewed by the 
Lakehead University REB. Youth workers at DAFC will approach current and former clients who meet 
eligibility criteria to inform them about the study (see appendix for script) with their being consented in by 
study staff. A rate of recruitment of 1/week would meet the study timeline and is feasible with respect to the 
numbers of potential participants (over 100) available at any given time. We will anonymously track the 
number of refusals at the level of approach by youth worker and refusal or failure to meet criteria. For the latter 
we will also note the reason (e.g., outside of age range, not in secure housing, etc.). 
 

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HOP-C Intervention  
 
The 6-month intervention has two major components that have been designed to address the core needs 
identified in previous research in an accessible, cost-effective, and scalable way – one focussing on general 
support and information needs and a second focussing on mental health. These two aspects of the intervention 
are offered concurrently in the 6-month period. In the feasibility study it was found that intensive support over a 
six month period served the objective of stabilizing participants in this critical time – solidifying connections 
with existing resources into which youth are bridged at the end of the six month period.  
  
General Support and Information  
 
 
Youth who have recently exited homelessness, as noted in the review, face considerable challenges in 
navigating systems (e.g., financial supports, criminal justice, housing) and addressing daily tasks such as 
budgeting. These young people also often feel isolated and disengaged at social and community levels having 
distanced themselves from homeless social networks. Additionally, youth who have a community support 
worker fare better in mental health and community stability domains (Kidd et al., 2014), most youth value 
information provided by peers who have greater experience, and most who have transitioned out of 
homelessness are reluctant to come to services located in homeless youth service spaces (Frederick et al., 2014; 
Kidd et al., 2016). To address these needs for information and support we would provide:  
 
1. Access to a transition-focused case manager: First, each participant will be provided with a transition-
focused community support worker who will assist in areas ranging from general support and 
encouragement to assistance in navigating relevant systems. They will have weekly contacts with 
participants by phone, informal contact via text and email, and at least twice per month will visit the 
participant where they are residing. It is expected that all participants will engage a community support 
worker. The transitional case managers hired into this role will be highly experienced in case 
management for youth, and will be supported by DAFC as an organization and team with participants 
registered as clients at DAFC.  
 
2. Access to peer support: In the model to be tested here we would (i) ensure that the peers are properly 
supported and supervised to ensure the quality of their work and their own mental health and, (ii) peers 
will have successfully sustained housing continuously for no less than 2 years and have successfully 
engaged in employment and/or formal education. There will be 2-3 Peers in the study. Peers will run 
drop-in style events/workshops every week with the aim that there will be a variety of interests 
represented (art, sports, video games, activism, etc.). They will also facilitate monthly social outings. 
Peers will be based out of the DAFC cultural service space and will be provided with the support of an 
experienced peer programming coordinator. They will work as a team and meet at least weekly to 
coordinate and review activities. The second element of Peer roles will involve, as a group, producing 
online content (e.g. short videos, blogs, etc.) on a range of topics (e.g., finding work, dealing with 
troublesome landlords, low cost entertainment), with topics developed in collaboration with participants. 

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This content will be made accessible to all study participants through a web portal and help extend the 
reach of the intervention. As with case management, the activities of the Peers will be documented on a 
weekly basis.  
 
Mental Health  
 
As described in the review, key aspects of the challenges faced by recently homeless youth include 
loneliness, maintaining hope, psychological distress, and challenges establishing a sense of meaning, purpose, 
and place through the transition process. To address these challenges we offer:  
 
1. Access to wellness-oriented group psychotherapy: Participants will be offered access to a weekly 90 
minute group intervention hosted at DAFC. The group content has several components informed by 
research evidence and will be co-facilitated by a doctoral or postdoctoral level Clinical Psychology 
Trainee supervised by Dr. Mushquash. The group will be run in an open format, allowing for flexible 
attendance, with enough groups running concurrently to ensure no more than 6-8 participants/group. An 
open rather than closed format is proposed based upon our experience in the feasibility study which 
indicated that the array of challenges experienced by these youth often precludes routine and consistent 
attendance and requires a flexible model. Should demand for the group exceed 6-8 youth per session a 
second group will be introduced to provide capacity.  
 
Sessions will have two components:  
 
a. Time would be given in all group sessions for a flexible narrative exploration of past and 
present challenges and successes following the practice principles of process-oriented group 
psychotherapy (Yalom, 2005). Challenges will be flexibly addressed in the group through mutual 
learning and support to as great an extent as possible.  
 
b. The second component builds upon research evidence suggesting that among at-risk youth and 
individuals experiencing complex trauma, emotion regulation, interpersonal effectiveness, 
and mindfulness interventions such as those extensively investigated in Dialectical 
Behaviour Therapy (DBT) are feasible and effective (Cloitre et al., 2011; Kerrigan, 2011). All 
sessions would involve a mindfulness component (incorporating both formal and informal 
mindfulness strategies). Mindfulness-based interventions have previously been demonstrated as 
feasible with homeless youth populations (Grabbe et al., 2012). Emotion regulation, distress 
tolerance/crisis management and interpersonal effectiveness components would be applied in a 
manner addressing the specific needs of group members and would be based upon DBT skills 
(Linehan, 2014). Other components, developed over the course of our feasibility study based on 
participants’ expressed needs, include self-stigma related to homelessness and mental health, 
trauma psychoeducation, anger management/conflict resolution, and healthy relationship groups, 
as well as practical skill workshops on topics of short-and long-term goal setting, managing 

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money, and time management. All approaches will be delivered in terms of process and the 
framing of content in a culturally relevant manner. As a point of reference, in the original study 
23 (75%) participants attended group at least once, and approximately 15 (50%) participants 
attended multiple times or regularly.  
 
2. Access to family counselling: There is evidence to suggest that reconnecting with family members 
facilitates successful transitions and addresses psychological distress. Participants will be given access 
to up to 3 family sessions on an as needed basis. These sessions would build upon the interpersonal 
effectiveness skills addressed in the group sessions. These family sessions will be provided by the 
postdoctoral level clinical psychologist. In the original study in only 2 instances was this aspect of the 
service provided.  
 
3. Finally, while not a formal component of the intervention, the Postdoctoral Fellows will have the 
capacity to provide individual psychotherapy to some participants should levels of distress or risk 
suggest additional supports are needed. This in and of itself will likely prove informative with respect to 
intervention design and assessment the potential of and need for individual interventions as an 
adjunctive component. In the original study, 10/31 youth have taken advantage of this aspect of the 
service. 
 
Needs Post-Intervention 
 
 
Post HOP-C intervention, participants needing further support will continue to have access to case 
management at DAFC among other DAFC services and will also be supported in engaging relevant local 
supports in education, employment, cultural and leisure domains.   
 
  
Measures  
 
Qualitative  
 
1. The youth participants will be interviewed on 3 occasions using a semi-structured interview format (see 
appendix for the interview framework; interviews done in person with participants paid $25 plus 2 transit 
tokens for each).  
 
Interview 1: Participants will be asked in broad terms about their history of homelessness and their past 
experiences in trying to transition out of homelessness, probing successes, strengths, and sources of 
adversity. We will also examine their expectations about the intervention – what they hope to achieve and 
any reservations they might have. The emphasis of these interviews is upon the transition out of 
homelessness process.  
Interview 2: Taking place at month 6 (or, for those who drop out, following their decision to do so) this 
interview will focus on their progress with transition, probing areas including housing, sense of community, 

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social factors, poverty, criminal justice involvement, and employment. This interview will also carefully 
examine their experience in the various aspects of the intervention – probing for each what is seen as helpful 
and not helpful, perception of impacts, and thoughts about how they might be improved. Expectations for 
the future will also be examined.  
Interview 3: Participants will be interviewed approximately 6 months after their T2 interview. This 40 
minute qualitative interview will focus on longer term trajectories in terms of housing, employment, 
education, well-being, and overall stability. 
 
 
2. Caseworkers, peers, service coordinators, Psychologists, managers will be interviewed immediately 
following the completion of the intervention. Interviews will be conducted in a complementary manner 
probing aspects of the intervention that seemed effective, challenges, and areas requiring improvement (see 
appendix). These individuals will be recruited by the study RA, their choice to participate or not will be kept 
confidential from the rest of the team, and data anonymized in any reports or other communications formal 
and informal.  
 
3. Detailed notes will be taken at all planning and supervisory meetings which will be subject to analysis 
to track the process of implementation and collaboration.  
 
Quantitative  
 
Descriptive measures: A detailed demographic profile will be developed including homelessness 
history (timeline), age, gender, ethnicity, sexual orientation/identity, housing arrangement, school and 
employment history, characteristics of neighbourhoods and services accessed, and interactions with institutions 
such as the criminal justice system and child protection. We will also carefully track attendance and time spent 
in the various aspects of the intervention.  
 
Scale measures: We will also employ quantitative scales that describe participants’ community 
participation, quality of life, mental health, hope, resilience, and social support. Each of these domains have 
arisen in previous qualitative and quantitative work as being critical in youths’ consideration of exiting the 
streets (Karabanow, 2006; 2008; Kidd & Davidson, 2007; Kidd et al., 2014; 2016). Quantitative measures will 
be collected at baseline and at 6 months. To accommodate possible low levels of literacy, the interviewer will 
give the youth the option to either record the answers themselves or via the interviewer.  
 
Community integration: Behavioural and psychological aspects of community integration will be 
examined using the 11-item Community Integration Scale (Stergiopoulos, Gozdzik, &O’Campo et al., 2014) 
which taps psychological (belongingness) and behavioral (activities) components of community participation. 
This measure was developed for homeless populations and proved psychometrically sound in previous work 
with formerly homeless youth, and is answered with a mix of dichotomous and 7 point Likert scale questions. 
Quality of life: This dimension will be measured with the brief World Health Organization Quality of Life Scale 
(WHOQOL-BREF) which has good to excellent psychometric properties of reliability and performs well in 
tests of validity (Skevington, Lofty, O’Connell, 2004).  

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Subjective Housing Stability: Along with a consideration or change in housing type, we will measure 
subjective housing stability using a scale developed and validated with transitional homeless youth populations. 
This is the Housing Security Scale, which contains 13 items on a 5 point likert scale (Frederick et al., 2014).  
 
Mental health: Mental health (and addictions) will be measured using the GAIN Short Screener (CAMH 
Modified) (Rush et al., 2013), which includes 6 internalizing items and 5 addictions items answered on a 5 point 
scale. This measure has demonstrated excellent psychometric properties with youth and allows for comparison 
with national norms. A cognitive measure of hope will be employed (Snyder, Harris, Anderson, & Holleran et 
al., 1991).This self-report questionnaire contains 12 questions that are each scored on an 8 point Likert scale 
and has likewise demonstrated excellent validity and reliability findings. Resilience will be measured using the 
14-item Resilience Scale (RS-14 Wagnild, 2010). This scale as excellent psychometric properties across a range 
of populations and has demonstrated good reliability among homeless youth populations. Items are answered on 
a five-point scale with responses ranging from strongly agree to strongly disagree  
 
Social Support: We will use a modified version of the MOS Social Support Survey (Sherbourne and 
Stewart, 1991) to measure social support. This survey measures 3 dimensions of social support: 
emotional/informational, tangible, and affectionate. It is a 15-item 5-point Likert-type scale. The scale shows 
good construct validity and reliability. Because the survey was originally designed for use with chronically ill 
patients we are (as have others with this population) modifying the 4 questions on tangible support to better 
reflect this population. Following other research with homeless populations we focus on the availability of 
people to lend $100, accompany to an appointment, provide food or a place to stay, and help with daily chores 
if the participant gets sick (Hwang et al, 2009). 
 
Goal Attainment: Recognizing the limitations of scale measures for capturing change among 
marginalized individuals with complex needs, we will use Goal Attainment Scaling. Goal Attainment Scaling 
(GAS) is a sensitive measure of progress on individually defined goals that has demonstrated good reliability 
and validity with marginalized populations (Hurn et al., 2006). Goal attainment scaling involves the setting of 
3-5 goals, each operationalized on a 5-point scale. Goals are individualized to the client and assessment of 
progress are determined through consensus of the client and case manager. 
 
Access to services: We have developed a brief set of questions to assess service needs and access. These 
questions focus on the services that the participants have access to outside of the HOP-C initiative, as well as 
questions assessing any gaps in service.  
 
Analysis  
As previously outlined, feasibility will be assessed primarily through the qualitative interviews with the 
quantitative measures being used for confirmation and triangulation. Our qualitative thematic analysis will 
involve the identification of core themes through structured coding (Boyatzis, 1998; Hsieh & Shannon, 2005) 
using NVivo Software. To maximize rigor, emerging categories will be discussed with the research participants. 
This process will deepen the discussion of the core emergent constructs and ensure better alignment of our 

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themes with the participants’ meanings. We will also enhance rigor through the use of multiple coders—the 
transcripts will be coded and analyzed by the research analyst, with the postdoctoral student and PIs 
subsequently reviewing the transcripts, coded text, and theme structure. The quantitative findings will be used 
to strengthen study findings through triangulation (Creswell, 2003; Bryman, 2006). For example, the qualitative 
code structure will be examined as a function of demographic factors and quantitative scores (e.g., level of 
community participation; quality of life). Examining quantitative and qualitative findings concurrently will also 
inform the design of future trials by assessing the adequacy of the quantitative measures for capturing change in 
core themes. Quantitative measures will also be used to develop a detailed descriptive profile of this group of 
participants. Pre-post change in all scales will be examined using paired sample t-test analyses and effect size 
examined with Cohen’s d. Some qualitative examination will also be made comparing mean change as a 
function of key demographics (e.g., gender) and degree of engagement in intervention components. Lastly, in 
resource utilization (both costs of service/youth and broader service/system contacts) will be quantified and 
examined through economic analysis to inform models of scale and viability. 
Research Question #2 – The Toronto Site 
 
To test the added benefit of the full HOP-C model as compared with case management in isolation, an 
open label, superiority randomized controlled trial will be used with the study site being Toronto.  
 
 
 
 
 
 
 
 
 
 
 
Youth Participants 
This study will follow most of the same core criteria for youth as the feasibility study in Thunder Bay. 
Participants will be 56 formerly homeless individuals between the ages of 16 and 26 who have obtained secure 
housing in a time period up to 12 months previously. Participation is not contingent upon ethnicity or cultural 
and demographic considerations. Enrollment will be opportunistic though may shift to purposeful should any 
substantial imbalances begin to emerge in the participant group (e.g., marked underrepresentation of males, 
overrepresentation of White youth) which would impact generalizability. Past experience with homelessness is 
operationalized as 6 or more months (not necessarily consecutive) of homelessness. Secure housing refers to 
either supported or independent housing. The original HOP-C study findings suggest that approximately 10% 
attrition is to be expected. Accordingly, having 28 individuals complete each arm of the intervention would by 
estimation be adequately powered to detect medium to large effect sizes.  
Recruit 
Evaluations:      Baseline/Pre                                    6 Months/Post 
Full HOP-C Service 
N = 28 
Transitional Case 
Management Only 
N = 28 

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In practice it is anticipated that the majority of participants will engage through LOFT community 
services, SKETCH, and Covenant House - the three principal partner organizations in this study. We will also 
approach organizations who engaged in the study in the feasibility phase, which included East Metro Youth 
Services, Eva's Place, Phoenix, and Satellite, Horizons for Youth, the Salvation Army, and YM/WCA.Youth 
workers at each site will approach current and former clients who meet eligibility criteria to inform them about 
the study (see appendix for script) with their being consented in by study staff. A rate of recruitment of 1-
2/week would meet the study timeline.  
Block randomization will be used to assign participants to either transitional case management only or 
the full HOP-C intervention. After randomization participants will complete written consent and baseline 
surveys. 
Interventions 
1. HOP-C: As noted above. As with the feasibility study, service provision will be provided by Loft and 
Covenant House for the transitional case management component, the peer component will be supported 
through Sketch Arts, and the mental health component will be provided by a post-doctoral fellow clinical 
psychologist and a mindfulness therapist from the Centre for Mindfulness Studies, supervised by Dr. Sean Kidd.  
2. Transition-focused case management: Participants in this arm will be provided with a transition-focused 
community support worker who will assist in areas ranging from general support and encouragement to 
assistance in navigating relevant systems. They will have weekly contacts with participants by phone, informal 
contact via text and email, and at least twice per month will visit the participant where they are residing. It is 
expected that all participants will engage a community support worker. The transitional case manager hired into 
this role will be highly experienced in case management for youth. 
Needs Post-Intervention 
 
 
For both arms, post intervention, participants needing further support will continue to have access to 
case management at LOFT or Covenant House and will also be supported in engaging relevant local supports in 
education, employment, cultural and leisure domains.   
 
Measures 
 
For each of the two contacts youth participants will be paid $25 plus 2 transit tokens.  
 
Quantitative measures are described above will be applied pre-post intervention. . 
 
Qualitative  
1. A post-intervention interview will take place for both the Transitional Case Management Only 
and HOP-C Full Service participants at month 6 (or, for those who drop out, following their decision 

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to do so). This interview will focus on participants’ progress in transition and will examine their 
experience in the various aspects of the intervention– probing for each what is seen as helpful and not 
helpful, perception of impacts, and thoughts about how they might be improved. Expectations for the 
future will also be examined.  
2. Caseworkers, peers, service coordinators, Psychologists, managers will be interviewed immediately 
following the completion of the intervention. Interviews will be conducted in a complementary manner 
probing aspects of the intervention that seemed effective, challenges, and areas requiring improvement 
(see appendix). These individuals will be recruited by the study RA, their choice to participate or not 
will be kept confidential from the rest of the team, and data anonymized in any reports or other 
communications formal and informal.  
 
3. Detailed notes will be taken at all planning and supervisory meetings which will be subject to 
analysis to track the process of implementation and collaboration.  
 
Analysis  
The data analysis strategy is as follows: (1) We will compare treatment and control groups at baseline on 
demographic and test variable measures using t-tests (continuous variables) and χ2 analysis (categorical 
variables). (2) We will develop a descriptive profile of session attendance. We will consider the participant as 
having been exposed to the intervention if they have been engaged in one or more aspects of the intervention in 
at least 50% of the weeks (>12/24). (3) We will compare the intervention groups and the control group on 
changes in housing, education, employment, and other key outcome domains noted above from baseline to the 
end of the intervention period. Analysis of variance (ANOVA) will be used for this comparison with the above 
variables being the dependent measures and treatment groups being the independent variable. For these 
analyses, a time effect will reflect changes across groups over time, and the group-by-time interaction will 
reflect changes over time between the groups. For all analyses   p < .05 will be used as the level of significance 
and effect size will be determined using Cohen's d. Qualitative post-intervention interviews will be analyzed, 
seeking to compare and contrast the experiences of the two participant groups, using the qualitative thematic 
analysis outlined in the Thunder Bay Site description. 
Knowledge Translation/Exchange 
 
 Knowledge translation and exchange activities will include (i) peer reviewed academic papers 
published on key process and outcome findings related to both the trial and the test of feasibility for HOP-C 
North; (ii) a forum hosted by CAMH and the Wellesley Institute to share findings with key providers and, 
through online capacity, engage national and international audiences; (iii) a forum hosted by Dilico 
Anishinabek Family Care (DAFC) and other local partners to share findings with key providers, and through 
online capacity, engage national and international audiences (iii) development of a HOP-C manual; (iv) 
engagement of policy makers at all levels in discussions regarding taking HOP-C to scale from local to national 
levels. 
 

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Originality  
 
 
To the best of our knowledge this study would be the first formal examination of an intervention 
for this population. It resonates with the increasing attention in policy and research given to transitional aged 
youth. Should this approach prove feasible, it will provide invaluable data with which we can go forward to 
conduct a large scale randomized trial. Furthermore, this project would be among the first to put forward one 
part of a potential solution to a major systemic failing of this marginalized population - the paucity of services 
available to see through the enormous efforts put in by all stakeholders to secure housing after traumatizing 
periods of homelessness. Without solutions such as these, we will continue to see resources and human potential 
wasted as youth cycle back into homelessness or experience inordinately protracted periods in a struggle to 
establish a life for themselves outside of homelessness. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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