Improving mental health services for homeless youth in downtown Montreal, Canada: Partnership between a local network and ACCESS Esprits ouverts (Open Minds), a National Services Transformation Research Initiative

Abstract Aim In many parts of the world, there is growing concern about youth homelessness. Homeless youth are particularly vulnerable to psychological distress, substance use and mental disorders, and premature mortality caused by suicide and drug overdose. However, their access to and use of mental health care is very limited. Methods The Réseau d'intervention de proximité auprès des jeunes (RIPAJ), a Montreal network of over 20 community stakeholders providing a wide array of cohesive services, was created to ease homeless youth's access to mental health and psychosocial services. Its philosophy is that there should be no “wrong door” or “wrong timing” for youth seeking help. In 2014, the network partnered with the pan‐Canadian transformational research initiative, ACCESS Esprits ouverts. Results Created through this partnership, ACCESS Esprits ouverts RIPAJ has been promoting early identification through outreach activities targeting homeless youth and agencies that serve them. An ACCESS Clinician was hired to promote and rapidly respond to help‐seeking and referrals. By strengthening connections within RIPAJ and using system navigation, the site is working to facilitate youth's access to timely appropriate care and eliminate age‐based transitions between services. A notable feature of our program, that is not usually evident in homelessness services, has been the engagement of the youth in service planning and design and the encouragement of contact with families and/or friends. Conclusion Challenges remain including eliminating any remaining age‐related transitions of care between adolescent and adult services; and the sustainability of services transformation and network coordination. Nonetheless, this program serves as an example of an innovative, much‐needed, community‐oriented model for improving access to mental health care for homeless youth.


Funding information
, is in the country's only province whose sole official language is French.
Montreal is also home to many English speakers; other linguistic minorities and immigrants. According to the 2016 census, 15.3% of Montreal's population was classified as low-income (Statistics Canada, 2017).
Since 1980, there has been a rapid increase in homelessness in Canada, including among youth (Gaetz, Dej, Richter, & Redman, 2016). Youth homelessness is not an exclusively Canadian concern. In the United States, for instance, a recent report estimated that 3.48 million young adults (aged 18 to 25 years) experienced homelessness or precarious housing over a 12-month period (Morton et al., 2018).
In the United Kingdom, it was estimated that 83 000 youth had availed homelessness services for a one-year period (Clark, Burgess, Morris, & Udagawa, 2015).
Notably, this estimate did not include youth living in unstable, precarious, or unsafe housing (e.g., short-term homelessness; couch-surfing or squatting in abandoned, unsafe buildings). Further, Indigenous peoples, transgender persons and newcomer immigrants are overrepresented among homeless youth.
Definitions of youth homelessness vary across contexts making comparisons difficult. The Canadian Observatory on Homelessness defines the youth homeless as including those "who are living independently of parents and/or caregivers, but do not have the means or ability to acquire a stable, safe or consistent residence" (Gaetz, Gulliver, & Richter, 2014).
Homelessness is both a consequence of and a contributing factor to mental health problems among youth (Folsom et al., 2005;Martijn & Sharpe, 2006). Most mental disorders have their onset in youth and homelessness significantly exacerbates risk (Kessler et al., 2005). Over 85% of homeless youth report high levels of psychological distress (Gaetz, O'Grady, Kidd, & Schwan, 2016). Compared to the general youth population, there is a substantially higher prevalence among homeless youth of mental disorders (Whitbeck, Johnson, Hoyt, & Cauce, 2004) and of specific disorders like psychosis or substance misuse (Martin, Lampinen, & McGhee, 2006;Roy, Haley, & Leclerc, 2004). Self-harm, and suicidal ideation and behaviours are also more frequent, with completed suicide and drug overdose being leading causes of premature death in this population (Roy, Haley, & Leclerc, 2004). Importantly, rates of mental disorders and distress are higher in youth who have been homeless for longer (Solorio, Milburn, Andersen, Trifskin, & Rodriguez, 2006 Housing, accompaniment.
Médecins du monde 18 y and older.
Psychosocial support, mobile health clinic.

En Marge 12-17
Youth 12-17 y old and their parents. Emergency shelter, short-term housing, supervised organization that runs a day centre, a night shelter and supervised apartments for homeless youth. Three staff members were hired for this project, including a coordinator of all activities and communication within RIPAJ and with outside agencies; an ACCESS Clinician (currently a social worker) to respond to mental health referrals or help-seeking within 72 hours; and a research assistant to conduct evaluations with youth per the ACCESS EO protocol.
Among the organizations visited most by Montreal homeless youth, the Dans la rue day centre was the first within the RIPAJ network to offer integrated services-meals, clothing, psychological and psychosocial services, music therapy, employment support, and alternative integrated schooling-in a youth-friendly environment. It is a key node within and a major philosophical influence on ACCESS EO RIPAJ. Annually, RIPAJ serves more than 1000 youth of whom about 300 to 350 are new.

| COMMUNITY MAPPING
An initial step upon joining ACCESS EO was to engage in community mapping to understand where and how homeless youth access mental healthcare, the factors hindering and facilitating such access, and youth's experiences and perceptions of accessing and receiving mental healthcare. ACCESS EO RIPAJ convened individual meetings with all partner organizations to complete questionnaires describing their targeted clientele, the services they offered, and their opinion on accessibility to their services and others in the network. Simultaneously, youth were involved in community mapping through different activities; for example, a mental health fair at which they pinpointed the organizations that helped them with their mental health on an innercity map of Montreal. This was done in an accessible manner using "post-it" notes on which they could write and draw. Youth were also invited to comment on the services received within the network. Viewing community mapping as a dynamic exercise that bears repetition, youth are still invited to mark and comment on the same map, which is hanging on a wall of the ACCESS EO RIPAJ youth space at Dans la rue.
Additional mapping activities have been undertaken in an ongoing graduate project that uses arts-based qualitative methods like PhotoVoice.

| APPROPRIATE CARE
ACCESS EO RIPAJ aims to deliver prompt, meaningful medical and psychosocial interventions to youth with mental health problems. Various interventions are available to youth including psychology and psychiatry consultations, psychotherapy, substance use treatment, and legal counselling, typically well within 30 days. These interventions are provided at RIPAJ sites by network professionals or by contracted professionals (e.g., a psychologist from a publicly-funded institute provides substance-related interventions at RIPAJ organizations).
A major strength of ACCESS EO RIPAJ is its ability to integrate under one umbrella services that address a range of homeless youth's needs (see Table 1). These include medical, psychological, psychiatric, education, employment, legal, housing, and financial services. For instance, la Clinique des jeunes de la rue, created within the province's public primary healthcare system, provides general health services.
These include access to general practitioners, dentists, social workers,   is ensuring the retention of the positions of the project coordinator and the ACCESS Clinician. The coordinator will ensure the maintenance of smooth links between network partners and the continuation of common training and early identification activities. The ACCESS Clinician will ensure continued early identification, rapid access and navigation supports. We will also strive to sustain the elimination of age-based transitions. For unavoidable transitions, we will continue easing the process by accompanying youth.
Our model serves as an example for other initiatives that seek to address the mental health needs of homeless youth. As our experience has shown, homeless youth are well-served by an integrated services approach in which mental healthcare is part of a broad-spectrum compendium of services and supports. Facilitating service access for hard-to-reach youth also requires mobile clinicians who are flexible enough to meet youth where and when they desire. The structure of ACCESS EO RIPAJ itself represents an innovative approach to crosssectoral and inter-services integration whereby diverse services align around a common objective without losing their individual identities and strengths or requiring co-location or extensive restructuring. and the Graham Boeckh Foundation. We would like to acknowledge the involvement of youth who participate to improve the ser-