When Tessie Orcino entered the Toronto East General Hospital's psychiatric ward two years ago, she didn't know she had taken the first step to ending nearly a decade of couch-surfing and homelessness.
The Philippines-born mother of three wouldn't be returning to her sister's care this time around.
"It's killing me. It's just toxic for me," Orcino recalled telling the doctor.
Her relationship with her sister was strained and Orcino's mental health was poor. She said a life as a single mother with a mortgage had simply been too much to manage. "I worked three jobs, four jobs, not sleeping. Forgetting about myself. I just wanted my kids to have the better things that I didn't have as a child," she said.
The doctor sent her to a women's shelter where a worker had her sign up for a project called At Home/Chez Soi, run by the Mental Health Commission of Canada. Soon, Orcino was part of the largest research project on homelessness and mental health of its kind in the world. She was given a choice of apartments to live in, a rent subsidy and a case worker for support.
The five-year project has housed about 1,000 homeless people with mental illness in cities across Canada since it began. The study randomized about 1,000 more applicants into a comparison group that was offered only the services they would already have access to in their cities. Randomization ensured researchers weren't only studying people who were motivated enough to apply for At Home in the first place.
At Home is based on the idea that people should receive housing first, instead of waiting until they're deemed ready to re-enter society. Participants don't have to accept treatment for mental illness or addictions, but most of them have chosen to get help. As the study approaches its final months, researchers say many participants are thriving.
Orcino has been accepted into George Brown's Assistant Cook program beginning in January. She volunteers, sits on committees, and says she wants to help women who have been abused. About 80 per cent of participants have been successfully housed, although some are in their second apartments.
There are five local studies across the country, each with its own specifications. In Toronto, care is geared toward the city's high proportion of ethnic minorities, nearly half of the homeless population.
Those involved with At Home say it's ground-breaking research with the potential to drastically alter not only our approach to homelessness or social policy -- but our entire health care system.
It's in part about gathering data that clearly demonstrates to policy-makers how health is inextricably linked to social situation, income and environment. That knowledge isn't new. But the researchers in this study say it's rarely addressed in our policies or understood by the public.
Orcino and many of her fellow participants illustrate a relationship research has established elsewhere: health begins long before a visit to the doctor, at work, at home, and in our neighbourhoods.
"It's like a game of musical chairs, when there are fewer chairs, those that are least able to compete for these chairs will be left standing," said Vicky Stergiopoulos, one of the Toronto site's principal researchers. She said a lack of elements such as affordable housing and employment opportunities for low-skilled workers are some of the main reasons people end up homeless in the first place.
Stergiopoulos said policies that address inequalities are lacking throughout North America, and those that do exist are often poorly implemented. At Home is investigating how well housing first works for homeless people with mental illness but it's also assessing cost-effectiveness. "It was both to close gaps in the knowledge base but also to make the case, the business case, for funding in Canada," Stergiopoulos said.
According to preliminary results, the costs of housing first are offset by savings in other social services. Patricia O'Campo, another principal researcher with the Toronto study, said that for every dollar spent on housing first, the system saved 54 cents from fewer days spent in jail, in the hospital, and fewer visits to the emergency room. For those who used services the most, those savings amounted to $1.54 for every dollar spent.
She says those are promising results for a study that promotes spending money on social programs during a time when that hasn't been a priority. "Right now Canada is on a path of increasing health inequities and that has a lot to do with the kind of policies that are put in place," she said. "Not just health policies but social policies, labour policies, economic policies. All of those impact the way in which health inequalities are expressed in society."
Stephen Hwang, one of the principal investigators for the Toronto site of the study, said Canada is falling short in several areas that affect population health, including income distribution and child poverty. "Canada is doing much worse than it thinks it is in addressing the social determinants of health," he said.
UNICEF ranked Canada 24th out of 35 industrialized countries this year in a report on child poverty. Similarly, the Conference Board of Canada gave Canada a "C" grade for income inequality based on what it deemed a significant increase in the gap between the rich and the poor in recent years.
Hwang said the At Home study could provide ways to improve those scores. "What we think we are going to achieve is an intervention that radically changes people lives and provides benefits to society at a very reasonable cost."
For now, the benefits are most apparent when we look at individuals whose stories are documented as part of the research. Take Steven Roberts, a young aboriginal man who suffered from depression and alcoholism when the study began. He moved to Toronto five years ago before discovering he was HIV positive. "It all just spiralled downhill from there," he said.
Roberts was diagnosed with depression the same year and he gave up his apartment to be with his partner. "From there I was in and out of shelters and in and out of that relationship." He was living at the Salvation Army Gateway shelter two years ago when he applied for At Home.
This December 3, Roberts will have been sober for six months. He lives in an apartment at Church and Wellesley and he has just completed training as a facilitator for harm reduction outreach, to help others with similar struggles.
"It's my way of giving back to the community," he said. He's also part of the Positive Youth Outreach advisory committee for the AIDS Committee of Toronto. Roberts says he's going to apply to the University of Toronto's Transitional Year Programme with the goal of becoming a social worker.
However, the first test of whether At Home will produce the kind of large-scale change its proponents hope to see will come at the end of March, when the original funding allotment for the project runs out. It's unclear whether the program will be given ongoing funding to support the people it provided with apartments.
Faye More, Project Site Co-ordinator for Toronto, says she's optimistic the funding will continue but she awaits word from the federal government. Participants have to pay 30 per cent of their rent during the study, which most pay using social assistance. If the funding were to end after March, those tenants would have to cover the entire cost of the rent.
"In some cases they wouldn't be able to do that. They wouldn't be able to afford it," More said. It's crucial for participants to remain supported, she added, in part because it opens the door for follow-up research on how they're doing.
Still, More said some have commented that $110 million is a lot to spend researching a method based on a simple concept -- homeless people benefit from housing. Organizations in the U.S. have already implemented housing first. But Faye says it's about taking action, here.
"One can say, 'Well that's common sense, that's common sense.' Yeah, well who did it? We did."
Lindsay Jolivet is an intern with the Evidence Network of Canadian Health Policy (EvidenceNetwork.ca). Her work has been published in the Montreal Gazette, Huffington Post Canada and broadcast on the CBC.