Toward the Quadruple Aim in Permanent Supportive Housing: Workplace Mental Health among Service Providers

Overview: This study explores the workplace mental health of Permanent Supportive Housing (PSH) providers in Canada. Through a mixed-methods approach, this study contributes to a gap in homelessness research on providers’ work life and includes implications for wider social work education and practice.Proposal text:

Background:
The Quadruple Aim is a policy framework for optimizing health system performance. Its four objectives are to simultaneously (1) improve population health, (2) enhance the service experience, (3) reduce costs, and (4) improve the work life of service providers (Bodenheimer & Sinsky, 2014). The framework is particularly relevant to the development and implementation of health and housing services for the homeless population, given that each of the four aims is considerably affected by the unique challenges associated with homelessness.

Permanent supportive housing (PSH) is an evidence-based intervention that is highly effective in stably housing people experiencing homelessness who have diverse support needs (Aubry et al., 2020). Research on PSH has largely focused on individual and systemic outcomes, but less attention has been given to the fourth aim: improving the work life of service providers. Nevertheless, this domain can have considerable impacts on how a program or service is implemented (Henwood & Tiderington, 2017). Occupational health and safety issues for service providers may undermine the effectiveness of PSH. Yet, the contributing factors to workplace mental health problems among PSH providers are unknown. This study examined the fourth component of the Quadruple Aim as it pertains to PSH service providers.

Methods:
This study used a sequential, equally weighted mixed-methods design to explore the mental health and work challenges experienced by PSH service providers in Canada. Quantitative data were first collected on the mental health and wellness of 130 service providers working in PSH, followed by semi-structured qualitative interviews with 18 providers. Binary logistic regression models were fitted to examine the predictors of high psychological distress among PSH providers. Thematic analysis of qualitative data was completed in several stages (Saldaña, 2013).

Findings:
PSH service providers with high psychological distress were significantly more likely to be younger, spend all or almost all of their time in direct contact with service users, and feel less socially supported by their coworkers. Financial problems and mental health deteriorations due to the COVID-19 pandemic were also significantly associated with greater distress. Three qualitative themes identified factors associated with PSH providers’ distress: (1) Sisyphean Endeavors, (2) Occupationally Unsupported, (3) and Wear and Tear (See Figure 1). These themes interacted, with systemic (Sisyphean Endeavors) and organizational (Occupationally Unsupported) issues intensifying the demanding nature of the work on a day-to-day basis (Wear and Tear), which then exacerbate existing interpersonal tensions among PSH support teams.

Implications:
The results of this study demonstrate the need for greater occupational and social supports for social workers, policies informed by direct care providers, and boundary-setting to prevent burnout within PSH settings. This study holds important implications for the improvement of housing and homelessness service organizations and demonstrates a need for intervention research aimed at improving workplace mental health. Additionally, more homelessness-specific social work education is needed to prepare future practitioners to address systematic challenges in the field and promote positive coping when working with vulnerable populations.