Table 2

Fidelity Assessment Tools and Summary of Findings from Anti-Racism/Anti-Oppression and Housing First Fidelity Evaluations at the Toronto site of the At Home/Chez Soi study
I. FIDELITY TO ANTI-RACISM / ANTI-OPPRESSION
FIDELITY ASSESSMENT TOOL SUMMARY OF EVALUATION FINDINGS
DOMAINS CRITERIA
I. Commitment toAnti-Racism/ Anti-Oppression 1. Agency has formalized its commitment to anti-racism and is committed to effective implementation of anti-racism. ▪Agency's commitment to anti-racism (AR) and anti-oppression (AO) principles was demonstrated via mission and policy statements, and mandates; management's accountability for and oversight of anti-racism activities; agency's participation, evaluation and formal commitment to addressing intersecting grounds of oppression.
II. Human Resource Environment II a) Anti-Racism Training and Professional Development II a) Anti-Racism Training and Professional Development
1. Agency provides staff with educational activities in which anti-racism and anti-racism related issues (including anti-oppression, cultural competence, holistic theory and practice, etc.) are addressed and staff is required to have adequate training on these topics ▪All staff are well oriented to the agency’s AR/AO commitments and participate regularly in ongoing AR/AO training. A member of management staff oversees AR/AO training.
II b) Recruitment, Hiring and Retention II b) Recruitment, Hiring and Retention
1. Agency is committed to hiring and retaining staff that are representative of the community served. Benchmarks include: ▪Recruitment and hiring of board, management and other staff was clearly informed by anti-racism competency considerations. Management and staff were reflective of the population served. Agency did well to track the ethno-racial composition of program participants and to target staff recruitment accordingly.
a) Recruitment and hiring procedures that consider and assess anti-racism competency;
b) Frontline AND management staff are reflective of the community served;
c) Management and staff performance evaluations include items related to anti-racism; and
d) Staff satisfaction and retention level data disaggregated by racialized group are obtained and reviewed.
III. Staff/Program Participant Engagement and Voice 1. Staff and program participants are able to have their concerns heard by management and influence direction-setting activities. Benchmarks include: ▪Agency offers numerous forums for staff and participants to have their concerns heard, including community meetings, staff retreats and staff meetings and there exists an informal culture of consultation and engagement in place, including an open-door management policy.
a) An effective formal discrimination complaint mechanism is in place for staff;
b) An effective formal discrimination complaint mechanisms is in place for program participants;
c) Frontline staff have a voice in agency/program direction-setting; and
d) Program participants have a voice in agency/program-direction setting.
IV. Advocacy, Community Building & Community Engagement 1. Agency is involved in advocacy-related and community building activities that serve the interests, health and wellbeing of its racialized program participants. Benchmarks include: ▪The agency evidences a keen appreciation of the importance of community engagement and advocacy, and engages in numerous advocacy-based initiatives and project partnerships. Agency staff have facilitated various community dialogues around health and broader issues in innovative ways that help counter stigmatization.
a) The agency communicates and disseminates program/service information to racialized communities in the service areas;
b) The agency forms alliances and partnerships with anti-racism and/or racialized-specific organizations in the service area;
c) The agency engages in social justice advocacy to change or influence legislation or other intuitions’ policies that negatively impact the health and wellbeing of racialized program participants; and
d) The agency consults with racialized community members and organizations in the service area regarding the health-related concerns of its community
V. Anti-Racism Frontline Praxis 1. Anti-Racism informs and is put into practice at the direct service level. ▪Case managers had an intuitive grasp of how AR/AO translates into their practice.
VI. Holistic Treatment 1. A holistic approach to health and wellness is adopted that informs program and service delivery. The program supports the following functions: ▪Client review during staff meetings and subsequent interviews with case managers and program manager demonstrated a very holistic approach to recovery planning, addressing broad social and cultural determinants of health. Numerous innovative alternative healing programs were offered by the agency (from yoga to drumming).
a) Staff explore participants’ cultural views of wellness and illness;
b) Programs and services address and engage the families of service users, as desired;
c) A profile of social and cultural resources for various ethno-racial groups in the service area is maintained and made available to program participants (houses of worship, community-based organizations, etc.); and
d) Staff support participants in accessing alternative treatments (including those that address emotional, cultural and spiritual wellbeing), as desired.
II. FIDELITY TO HOUSING FIRST
I. Housing Choice & Structure 1. Program participants choose the location and other features of their housing (decorating, furnishing, etc.). ▪The program meets the housing choice and structure domain with the highest standards for all criteria except for housing availability.
2. Program participants are moved quickly into housing of their choosing once they acquire housing subsidy.
3. Housing tenure is assumed to be permanent with no actual or expected time limits other than those on standard occupancy agreement. ▪With respect to housing availability, about two-thirds (67%) of the participants moved into the housing unit of their choosing within 6 weeks of receiving housing subsidy. Housing delays occurred for some participants due to trying to find the right housing that fits the participant’s preferences. Participants have an extraordinary amount of choice in location and sometimes the search for a “perfect match” for housing can significantly delay move-in and places strain on team resource.
4. Housing is affordable (<30% of income).
5. Housing is integrated in scatter-site private market housing which is otherwise available to individuals who do not have psychiatric or other disabilities (also, <20% of units in a building are leased out by the program).
6. Housing is private (no expectation to share living spaces).
II. Separation of Housing & Services 1. Participants are not required to demonstrate housing readiness prior to access to housing units. ▪The ER-ICM program meets the separation of housing and services domain with the highest standards for all criteria.
2. Tenancy is not linked in any way to adherence to treatment or service provisions.
3. Program participants have legal rights to unit as per lease or occupancy agreement, with no special provisions added.
4. Participants have access to a new housing unit if they lose their housing access.
5. Participants continue to receive services even in the event of housing loss (eviction, inpatient treatment, etc.).
6. Social and clinical service providers are not located at participants’ residence.
7. Social and clinical service providers are mobile and can deliver services at locations which the participants choose.
III. Service Philosophy 1. Participants choose the type, sequence and intensity of services on an ongoing basis. ▪The ER-ICM program meets the service philosophy domain criteria for all areas with the exception of harm reduction approach, motivational interviewing and person-centered planning, where additional training would be helpful.
2. Participants with psychiatric disabilities are not required to participate in treatment or take medication.
3. Participants with substance use disorders are not required to participate in treatment.
4. Program utilizes a harm reduction approach.
5. Program staff use principles of motivational interviewing in all interactions with participants.
6. Program staff use an array of techniques to engage difficult-to-engage consumers including a) motivational interventions; b) therapeutic limit-setting interventions. The program also has a process for identifying the need for assertive engagement, including measuring effectiveness of assertive engagement techniques and modifying these approaches as necessary.
7. Program does not engage in coercive activities towards participants (e.g. leveraging housing or services to promote adherence to clinical provisions OR having excessive intrusive surveillance with participants).
8. Program engages in person-centered planning, including a) development of formative treatment plan; b) conducting regular scheduled treatment planning meetings; c) actual practices reflect strengths and resources identified in the assessment.
9. Program systematically delivers specific interventions to address a range of life areas (e.g. physical health, employment, education, social support, recreation, etc.).
10. Program increases participants’ independence and self-determination (by providing choices as much as possible).
IV. Service Array 1. Program offers housing support services to help participants retain housing.1 ▪The ER-ICM program meets the service array domain criteria for providing housing support and social integration services, brokering psychiatric services, and involvement in inpatient treatment admission.
Program provides active referrals and conducts follow-up for the provision of:
2. Psychiatric services2
3. Substance abuse services2
4. Employment and education services2
5. Nursing/medical services2
6. Program provides services supporting social integration, including a) facilitating access to and helping participants develop valued social roles and networks within and outside the program; b) helping participants develop social competencies to successfully negotiate social relationships, c) enhancing citizenship and participation in social and political venues.
7. Program responds to psychiatric or other crises 24 hours a day.
8. Program is involved in inpatient treatment admission.3
V. Program Structure 1. Program has priority enrollment for individuals with obstacles to housing stability (homelessness, severe mental illness, substance use) ▪The ER-ICM program was able to meet almost all of the criteria outlined in the Program Structure domain. Development of new strategies for improving contact with difficult to see participants will help ensure ongoing contact. Establishing new opportunities for participant involvement in the program would increase their representation in program operations.
2. Program has a minimal threshold of non-treatment related contact with participants
3. Program has a low participant to staff ratio (20 or fewer participants per 1 full time staff)
4. Program has a team approach
5. Program has frequent meetings where program staff plan and review services for participants
6. Program has weekly meeting/case review.4
7. Participants are represented in program operation and have input into policy (including roles on committees and governing bodies as well as peer advocates)

1 Housing support services including services such as neighbourhood orientation, landlord/neighbour relations, property management services, assistance with rent payment or subsidy assistance, utility setup, co-signing of leases, budgeting and shopping.

2 The criteria for successfully brokering each service includes: 1) The program has established formal and informal links with several providers; 2) The program assesses participants in order to match participant needs and preferences to providers; 3) The program assists participants in locating, obtaining and directly introducing participants to providers; and 4) The program conducts follow-up, including communication with other providers regarding services on a regular basis and coordinating care.

3 The program works with inpatient staff to ensure proper discharge with the following steps: 1) program initiates admissions as necessary; 2) program consults with inpatient staff regarding need for admissions; 3) program consults with inpatient staff regarding participant’s treatment; 4) program consults with inpatient staff regarding discharge planning and 5) program is aware of participant’s discharge from treatment.

4 Weekly meeting/case review should serve the following functions: 1) conduct a brief but clinically relevant review of half the caseload; 2) discuss participants with high priority emerging issues in depth to collectively identify potentially effective strategies’ and approaches; 3) identify new resources within and outside the program for staff and participants; and 4) discuss program-related issues such as scheduling, policies, procedures, etc.

Stergiopoulos et al.

Stergiopoulos et al. BMC Health Services Research 2012 12:345   doi:10.1186/1472-6963-12-345

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