Much of the information in this article is based on a visit to Dr Olivier Farmer’s team at the PRISM program located in the Old Brewery Mission in Montreal that Peter Martin of the Toronto Alliance to End Homelessness and I made on 28 October 2025. And from frequent consultation with Dr Farmer since.
THE PROBLEM
According to the Street Needs Assessment there are 15,400 homeless people in Toronto. 40 % have a mental illness-mild to severe.
Housing First programs are recognized as the most effective policy to address their problems . The person is moved rapidly into housing where they will receive treatment for their mental illness and help with their many social problems.
But, a proportion of the homeless suffer from such severe mental illness that they lack the capacity to engage with Housing First and other supports.
Their behaviour, disorganized thinking, impaired reality testing , and poor judgement guarantees they would fail.
Who are these individuals ?
Those with schizophrenia and schizoaffective disorder and bipolar disorder. Many, also have substance abuse disorder.
How many are there in Toronto ? Based on a prevalence of schizophrenia and schizoaffective disorder of 13 %,( 11x that of general population) adds up to 2000 (AJP 2013 Vila-Rudriguez et al)
Based on a prevalence of bipolar disorder of 11 % ( 4x that of general population ) adds up to 1700. However there is a wide range of severity in this condition, so, the number with severe conditions would be less.
Currently, the only way to treat illnesses of such severity is in a psychiatric ward.
The main problem with this is that many severely mentally ill homeless people would likely refuse to be admitted, and thus may be involuntary admitted. . As a result, they sometimes have a very traumatic entry into hospital: handcuffs, restraints, seclusion rooms, forced injection. Some never want to have anything to do with mental health services ever again .
There have been increasing calls by politicians to increase involuntary hospitalization for the homeless mentally ill.
Premier Eby in 2024 announced plans for involuntary hospitalization for those with mental health and addiction disorders in secure facilities in correctional facilities.
Brampton mayor Patrick Brown is a strong advocate for this.
And, most concerning and recent- the Ontario Big City Mayors ( 29 in all ) were asking Doug Ford to invoke the notwithstanding clause to enable easier forced hospitalization . They have since dropped that request due to pushback from civil liberties groups- and on their website I sense discord and confusion about this issue.Also Doug Ford said his Mental Health minister Tibbolo is “ a big fan of compulsory hospitalization”. Tibollo has denied this and maybe Ford has walked back that comment.
Where would the psychiatric beds for increased involuntary admission come from ?
Ontario has only 33 psychiatric beds per 100, 000. There is no recognized gold standard for psychiatric bed provision. However 33 beds per 100,000 is inadequate by any reckoning. In a 2024 systematic review of bed need estimates by Mundt et al ,the median was 47 beds per 100,000, close to the median bed provision of 44 per 100,000 in high income countries . A review by Alison et al concluded that adverse effects such as boarding in the ER ( waiting for days in the ER for a bed ), and increased suicide risk, may worsen as total bed numbers fall below a range of 50-60 beds per 100,000 population. The OECD average is 6.2 per 100, 000 ( Mundt et al )
For various reasons, twelve countries and the province of Quebec have created systems of alternatives to hospitalization, particularly psychiatric hospitalization at home-known as Intensive Home Treatment ( IHT)-an innovation in which Ontario has shown no interest , and which would have helped offset its lack of beds.
.Hospital care for this population is very expensive – mental illnesses are the second most expensive group of disorders out of 20 -exceeded only by diseases of the circulatory system -heart attacks and strokes ( EBIC 2010).
$ 414 / day psychiatric hospital.
And yet, untreated they cost $ 59,000 / year in Toronto : shelters , ER visits, ambulance trips, police calls, court appearances, jail ( Latimer CMAJ) Studies show costs can be as high as $ 342,000 a year .( At Home/Chez Soi project ). One case in Cornwall , Beverly Cleary , a homeless retired nurse with bipolar disorder featured in a CBC article is a poster child for why a different approach is needed. She cost the system $ 800, 000 since 2018.
Cornwall police said they had “ twenty like Beverly”. They picked five individuals from the group and found an average of 53 occurrences requiring police response in 2024.
Surely there must be a better way I thought ?
THE SOLUTION
Allow me to digress at this point . I started Canada’s first psychiatric hospitalization at home program -otherwise known as Intensive Home Treatment ( IHT) at Kitchener’s Grand River Hospital called the Hazelglen program in 1989. It provides an alternative to admission by treating people at home by a clinical team that makes frequent home visits and provides 24/7 clinical coverage . It is available in 12 countries . IHT is cheaper than and as safe and effective as hospital and patients prefer it.
Since my book on IHT was published in 2004, I have been on a mission to introduce IHT in Ontario.
So, I am primed to be aware of any references to it.
So, earlier this year these words caught my eye : “ psychiatric hospitalization in the community “; Montreal psychiatrist Olivier Farmer was describing a program called PRISM
I immediately recognized PRISM as a game changer. PRISM is an Intensive Home Treatment program, where ” home” is PRISM, in a homeless shelter.
PRISM ( Projet Reaffiliation Itinerance, Sante Mentale) -mental health and homelessness reaffiliation project was co-founded by Dr Farmer and Dr Lison Gagne in 2013 for which they received a Governor General’s award in 2018
Citation:
By offering intensive psychosocial support as well as medical and psychiatric treatments and follow-ups, this initiative helps homeless people leave the streets. In partnership with several community organizations, this program has changed the daily lives of nearly 150 homeless individuals by providing them with housing stability and facilitating their social reintegration.
It focuses only on serious mentally ill homeless with psychosis -schizophrenia, schizo affective disorder, psychotic depression, bipolar disorder, and many also with a substance abuse disorder .Instead of being hospitalized these patients are treated in existing homeless shelters such as the Old Brewery Mission.
Referrals: 30 % come from hospitals and other clinical programs. Many are referred by the shelter itself by the shelter workers. Other referrals from other shelters, police, immigration lawyers, and prisons.
Dr Farmer said PRISM is often the service of last resort for individuals.
Patients are housed in a separate section of the shelters with private or semi private rooms for 8-16 clients. There are large lockers, a lounge with sofas and computers. Clients can come and go as they wish and get all their meals supplied .
They pay $ 335 rent from benefits. They have to agree to seek housing and accept treatment.
PRISM uses a harm reduction approach but clients are not allowed to consume addictive substances in the shelter.
A clinical team of SW, RN, shelter case worker and PT psychiatrist is embedded in the shelter and work five days a week. Medication supervision and security/surveillance 24/7 is provided by shelter staff . PRISM does not provide 24/7 clinical coverage ” which would consume a lot of resources for little or no benefit ” said Dr Farmer, who added, ” I don’t even know why 24/7 coverage would even be a thing for community-based services except in the most exceptional circumstances”.
Such circumstances may require the city wide mobile crisis service who also assist the police and which operates independently from PRISM. Dr Farmer: ” We do link with them when we have unstable clients which are likely to elicit 911 calls, so they have a heads up, but they are part of the overall emergency mental health response. They do evaluate our patients on occasion to guide police work on weekends, evenings and nights , and are a great partner. But there is no specific partnership with us.”
This a similar level of coverage to what we had in the Hazelglen IHT service in Kitchener. We found that impending crises were predictable because the staff knew the client and their supports-usually family, due to frequent visits to their homes. Clients and families could be coached as to what might occur in the next 12-24 hours and how to prepare.
Staff were available by phone 24/7 which was usually sufficient to settle clients, who were reassured that we would be at the house the next morning .
On the rare occasion this was not sufficient, we had a contract with a taxi company who could take clients to the 24 hr crisis clinic staffed by experienced nurses, adjacent to the ER, where, if necessary they could be seen by the on call psychiatrist.
PRISM has a partnership with a hospital psychiatric department. The SW and RN are employees; administratively in an “ off campus out patient program .” The psychiatrist is on staff at the hospital, and uses the hospital chart ( he has an office with a computer linked to the hospital system) The connection to the hospital allows them to use the hospital in a seamless manner when required for example if clients need to be admitted.
In addition, PRISM relies on multiple other partnerships. The most important of these is between a homeless shelter and the formal health and social services system. To set up and oversee a PRISM facility, representatives of a shelter and of the health and social services system create a ” governance committee” that meets two or three times a year.
PRISM has ongoing partnerships with non -profit organizations that deliver Housing First services. It relies on partnerships with social assistance officers to expedite reinstatement of social assistance benefits , with staff at other healthcare organizations to arrange for general healthcare, and with the provincial government to obtain new public health insurance cards.
PRISM can be conceived as a hospitalization in the community. Discussions with clinical teams revealed that many individuals referred from the emergency department or coming from the street may have needed hospital admission without PRISM. PRISM provides a setting for inpatient care that is more familiar to clients, and has a less regimented approach.
A psychiatrist is available at short notice and staff are present at all times ( PRISM staff during working hours and shelter staff the rest of the time
Statistics :
After 8-12 weeks, 75 % stably housed -62 % still housed after one year .
At discharge, 78 % are engaged with psychiatric follow-up, usually by a mental health OP clinic. 10 % need ACT
Cost to health care system $ 5000-75000 , per treatment epidode, plus psychiatrist’s billing of the provincial health insurance plan.
Cost to the shelter: cost of building modified section, meals, shelter worker’s salary ( PRISM in a shelter attracts donations ) .
Here are some of the things we learned from Dr Farmer during our visit.
“PRISM is primarily a psychosocial/recovery program, NOT a treatment focused program. Treatment supports the psychosocial goals but does not supersede it. In most cases I try to convince people to accept a long-acting antipsychotic injectable (this is what we do at least 75% of the time) and then my implication is supportive but I am never considered the main caregiver. Think of it as a day hospital intensity, but with room and board. We work best with chronically psychotic individuals without major behavioural issues”
“ Our best antipsychotic is not chemical in nature, it is the fact that our program provides quiet (relatively) sleeping arrangements, the possibility to remain 24 hours a day seven days a week at the same place, and three meals a day. This form of respite from the constant tribulation of homelessness is what makes screaming and agitated people (we have those aplenty) become sufficiently calm to allow for an interview and to propose a plan, including treatment. Our main population is people with triple diagnosis of a major mental health condition, substance use, and antisocial personality disorder. Our direct connection to the hospital (as I am myself an inpatient psychiatrist) allows us to use the hospital in a fairly seamless manner when it is required. I think you have to see this more as an integrated network of services, of which PRISM is a part, rather than PRISM as an isolated program. This is an important consideration before trying to replicate the program. You also need follow up subsidized housing and home based support from community organization and clinical teams, as we discussed previously. I see the whole as a care trajectory and not individual programs functioning independently.”
“The vast majority of our patients are stimulant (crack and Meth) users, and we have good partners for opioid substitution treatment. Alcohol is surprisingly rarely an issue. We use money management, motivational approaches and some coercion (threat to remove patients from the program which is a significant loss in comfort and opportunities) if drug use is clearly an obstacle to the shared goal of obtaining permanent housing. Treatment of any kind is never the main purpose, it is always working towards permanent housing. We have had completely untreated patients with psychosis successfully enter housing”
“Part of the success of this program is based on the partners identifying candidates and doing the first canvassing (explaining the program and soliciting adherence to an evaluation). There are relatively few self referrals, as the homeless mentally ill with psychotic disorders rarely have enough capacity to identify their needs and initiate self referral.”
“We have elaborated profiles of patients most likely to benefit from our program which our partners are aware about. The mere presence of PRISM has in itself galvanized the shelter and the community organizations to invest in housing first programs that can usually handle milder forms of mental illness. We also provide support unofficially to these programs on occasion”
One other reason why the PRISM program resonated with me was the immediate recognition that I had been “ doing PRISM “ in 1992.- with one case. Hazelglen, the IHT program I started , received a referral from the Kitchener downtown men’s shelter -the House of Friendship. Stefan as I call him was in his 40’s and suffered from extremely severe chronic schizophrenia -one of the sickest patients I have encountered in over 40 years of practise.
Here is his story. He had assaulted a female relative, spent the night in jail and was then admitted to the House of Friendship.He refused all help- not even disability benefits, not even replacement of his dilapidated boots.
He literally lived on a bench in downtown Kitchener. He would refuse offers of money from passers-by, saying give it to someone who needs it more. The shelter went through a cycle with him over the years. They would admit him. He would refused all help-not even enrolment in disability benefits, not even to replace his dilapidated boots. He refused all offers of treatment and supportive housing . He refused to bathe. He smelled so bad, the other residents complained and they would reluctantly discharge him when spring came. This cycle continued for some years.
Whenever he heard we were coming to see him , he would leave; we had to track him down on the street. Most communication was through his long term shelter worker
We were eventually able to establish him on a depot IM antipsychotic medication. The effect was transformative :new boots, enrolled in disability benefits, then finally transfer to a supervised residence and follow up in a mental health out patient clinic.
With extremely severe symptoms, and impairment, and not aggressive, Stefan appears to be a prototypical patient. Dr Farmer: “ what you describe with Stefan is basically what we codified and put to scale ( and can perform in 50-60 days “)
There are four PRISM programs in Montreal and three in other Quebec cities; the government plans to establish others .
BENEFITS OF PRISM
- Would decrease need for involuntary hospitalization
PRISM is essentially a psychiatric hospitalization at home program where “ home” is PRISM. Studies in Ireland and Italy show that involuntary hospitalization is reduced by 50 %, 80% respectively in such programs.
My experience in IHT is that we treated many patients at home, and that if this option had not been available, I would have admitted them to hospital, involuntarily if necessary. It is the hospital that patients want to avoid, not the treatment .
Dr Farmer says that PRISM is a “ big fat worm”; the offer of a private or semi-private bedroom, and three meals a day, a private lounge and freedom to come and go overcomes clients’ resistance to treatment.
This feature of PRISM is particularly important at this time ,in order to provide an evidence based alternative to hospitalization ,enabling us to push back against the growing calls for more use of hospitalization, forcibly if necessary .
2 Success at linking clients to stable housing
Evidence: 2023 Canadian Journal of Psychiatry report
76.7 % clients were discharged to housing modalities and 62.55 were living at the same home address at 1 year follow up
PRISM allows a more precise assessment of housing needs than services that use immediate placement .
- Success at linking clients to psychiatric follow-up at discharge
Evidence : Canadian Journal of Psychiatry report – 78 % discharged to psychiatric follow up: 50-60% mental health OP; 10% need ACT ( Olivier Farmer )
Linkage is accomplished by a warm handover, in which staff accompany clients to their first appointment.
- Effectiveness of addressing client’s many social problems such as lacking ID, lacking social benefits , lacking health cards, and many others
A qualitative study in PLOS ONE , 2021, Voisard et al, of clients’ experience in PRISM compared to in hospital.
The unique structure of PRISM. The mental health service component is formally linked with Housing First programs and other social agencies representatives of which create a “governance committee” that meets 2-3 x a year.
- PRISM reflects a deep understanding of its clients needs
PLOS ONE qualitative study:
PRISM allows them to continue to be involved in the day-to-day activities of that were part of their lives prior to being part of PRISM
This enabled continuity between the myriad resources and personal strategies used to survive on the street and PRISM. It allowed for continued investment in some aspects of their informal networks .
They valued the space for recovery provided by the safe, warm support, in a familiar environment, three meals a day and a private or semi-private room.
Clients can participated in shelter life on-site by helping in the kitchen or helping with inventory.
They appreciated the multi-modal approach to treatment which provided a wide array of expertise for clients to address a variety of issues in their lives; not only concerning medication and housing . This assistance may involve simple tasks such as looking for the contact information of a hairdresser with a client and accompanying them there, if needed, or resolving larger challenges such as legal or asylum-seeking problems.
( With severely ill patients waiting in the ER sometimes for days to be admitted, the severe shortage of psychiatric beds creates intense pressure on hospital staff to discharge patients as soon as their symptoms and behaviour have decreased sufficiently, leaving no time to address the severe social problems that homeless patients have such as no ID, no source of income and no place to stay) .
They were overwhelmingly ambivalent about their past experience with the mental health system .A recurring sentiment was that they benefited from a psychiatric stay ,but highlighted the inhospitable nature of of the experience and its emphasis on medication.
The onsite psychiatrist listened to and respected their concerns and requests about medication
The talk therapy with the psychiatrist left them feeling heard and understood without being judged.
6.PRISM is cheap compared to hospital treatment
PRISM costs to the healthcare system is $ 5000-7,500 per episode ( There is a cost to the shelter to cover renovations, salary of shelter worker and meals )
- PRISM saves money by taking clients off the street and housing them ( see above statistics in section I regarding cost to society of untreated homeless mentally ill individuals.)
- PRISM is specifically designed as an alternative to hospitalization . This brings the following benefits
It helps offset the inadequate psychiatric bed provision in Canada. ( see above in section I)
PRISM clients avoid the following negative experiences associated with hospitalization.
a.Boarding in ER’s: waiting days in the ER for a psychiatric bed.
This is a major problem in Canada according to an article by Eddie Lang , Head of emergency medicine at U of Alberta in a Healthy Debate online journal
Boarding causes dysfunction in the whole ER and contributes to burnout of staff.
Patients often deteriorate , and need chemical and physical restraint .
b.2.3 % patients discharged from psychiatric facilities are discharged to homelessness. This is associated with higher rates of psychiatric readmission, higher rates of mental health related ER visit at 30 days and 46 % had no outpatient care in the 30 days following discharge.
:2019 study by Laliberte, Stegiopoulos et al
c.Psychiatric hospitalization can be traumatic for some patients.
Here is the Mental Health Commission of Canada’s comments on this
Toward Recovery and Well-Being ” the report of the Mental Health Commission of Canada makes the point that for some , fear of restraint is like the elephant in the room, a continuous threat that shadows the recovery process. Recovery –oriented mental health policy and legislation need to uphold the principle of least intrusive interventions”. (Eg Psychiatric Hospitalization at Home or community programs such as PRISM)
- PRISM, a psychiatric hospitalization at home/community is the only program that is in accordance with the 2017 Canadian Guidelines for Community Treatment of schizophrenia and psychosis . These guidelines are based on the UK’s NICE guidelines. Crisis Resolution and Home Treatment is the UK term for psychiatric hospitalization at home/community.
Recommendation 11: Crisis Resolution and Home Treatment Teams
Offer crisis resolution and home treatment teams as a first-line service to support people with psychosis or schizophrenia during an acute episode in the community if the severity of the episode, or the level of risk to self or others, exceeds the capacity of the early intervention in psychosis services or other community teams to effectively manage it.
[NICE (Conditional)]
Recommendation 12: Crisis Houses or Acute DayFacilities
Consider acute community treatment within crisis resolution and home treatment teams before admission to an inpatient unit and as a means to enable timely discharge from
inpatient units. Crisis houses or acute day facilities may be considered in addition to crisis resolution team and other home treatment teams depending on the person’s preference and need.
[NICE (Conditional)]
WHAT ARE THE ORIGINS OF PRISM ?
The At Home /Chez Soi project was a federally funded research program of Housing First in five cities . Housing First is a model of treatment in which mentally ill homeless people are rapidly installed in stable housing, then enrolled in ongoing psychiatric treatment in ACT and Intensive Case Management programs.
Started in 2008 , ending in 2012 ,it was such a success that Provincial governments were willing to continue the funding. Except Quebec, where the government perceived At Home as an overreach of a federal entity into Provincial jurisdiction .
Efforts were made to create a “ Made in Quebec” program that could keep much of the relevant functionality of the previous teams but still be branded as a unique solution that the Province could get behind.
PRISM became the home brand of Housing First with the added feature of being embedded in a shelter.
There was a growing realization that there was an underserved population in the homeless mentally ill for which “we were doing a terrible job “ ( Dr Farmer )
This population needed mental health services but the hospital environment was perceived as hostile and uncomfortable .
Outreach services to the shelter by nurses was completely insufficient.
It became clear that services had to be shelter based with a degree of intensity that allowed treatment of active psychotic symptoms ( 75% clients on depot IM antipsychotic drugs ) and the kind of psychosocial support that gets people moving into permanent housing .
PRISM provides the following:
Low-barrier entry into the shelter and embedded psychiatric assessment within 72 hrs.
Time limited residential treatment 8-12 weeks.
Dedicated effort to establish ID, obtain disability benefits, and a health card.
Dedicated housing transition workflow with an explicit program of permanent housing and warm handover to community mental health services.
What is distinct about PRISM is that is designed as one tightly integrated pathway; (assessment +stabilization + housing transition + handover to ongoing supports ) are all contained in one single package.
In contrast, take, for example a common occurrence with this population- a police call. The man is actively psychotic, hearing voices, delusional, and bothering passers by his scary behaviour. The police may have a mental heath crisis worker with them. Together they decide that he is seriously ill and needs hospital treatment .
They take him to the ER. This can mean a long wait, taking up police time. Let’s say the man then gets admitted to the hospital but will have to wait for days for a bed in the ER and may deteriorate further with this stress and need sedation or even restraint.
He then gets admitted to the psychiatric ward and gets the appropriate treatment, recovering barely enough to be discharged because of pressure on beds. Hospital staff may not have had time to adequately deal with his problems with ID, disability benefits and a health card.
He is linked to a clinical transition team who will support him during the process of connecting him to housing. Also, he has to be linked up with mental health follow up.
For a severely mentally ill, often addicted individual, there are many opportunities for failure in this pathway of numerous linkages from street to housing with mental health supports.
.