More than a Roof and a Key Required: Exploration of Guiding Principles for Stabilizing the Housing Trajectories of Youth Who Have Experienced Homelessness

: Youth homelessness represents a persistent and significant challenge for service sectors with limited best practice guidance. Housing supports, in particular, are widely deployed, with the practice-oriented literature providing little detail regarding service design beyond broad domains such as employment support and life skills coaching. The present multiple case study investigation was designed to develop a preliminary understanding of the guiding principles that attend the development of interventions that support youth exiting homelessness in the Canadian context. These case studies were conducted with a diverse group of five organizations recognized as sector leaders, with findings considered in light of practice standards from the better-established adult housing literature. Key findings with respect to service models included the strategies used to provide flexible, culturally responsive, tailored services with an emphasis on specialist support. Implementation factors included the navigation of strategic partnerships, the use of data in capacity-building, and the benefits and drawbacks of larger, centralized service environments versus smaller, dispersed environments. Youth-specific considerations in housing stabilization models are highlighted. This work contributes to a growing body of literature that seeks to articulate best practices in the effort to address and prevent youth homelessness.


Introduction
Youth homelessness is a persistent problem globally in both high-and low-income contexts.In Canada, at least 35,000 to 40,000 youth experience homelessness annually [1].In the United States, 4.3% of households with 13-17-year-olds and 12.5% of households with 18-25-year-olds were comprised of a youth or youths who have experienced homelessness [2].The populations of youth experiencing homelessness are diverse, with an array of intersecting risks associated with pathways into homelessness.Risk domains include (i) youth characteristics with Black, Indigenous, 2SLGBTQ+ identities having pronounced and unique risk implications, (ii) social context risks such as family instability and exposure to violence and neglect, and (iii) contact with child protection and juvenile justice systems [3].Mental health and addiction challenges are common, with depression and trauma particularly prevalent [4].Mortality rates, primarily due to overdose and suicide, are many times those of comparable general populations [5].These risks occur in parallel with a range of coping activities, efforts to survive and cultivate resilience, and activist and artistic engagement, which have been extensively documented [6].Service systems accessed by youth at risk of and experiencing homelessness have largely taken the form of crisis response through interventions such as drop-ins and shelters.However, the field is seeing an increasing emphasis on housing stabilization, which involves assisting individuals who have experienced homelessness and housing precarity with the necessary supports to exit as quickly as possible and ensure they do not cycle back into homelessness [7].In addition to providing housing units, housing stabilization aims to improve outcomes in areas of health, employment, education, and social inclusion.One approach is through supportive housing, which combines housing or rental assistance along with individualized, flexible, and voluntary support services.The Housing First model is one such example.Housing First prioritizes the rapid placement into scattered-site housing of individuals experiencing homelessness and mental health and addiction challenges.Housing First combines several elements, including a low-barrier process for housing placement, the provision of a unit, and integrated supports.Youth data from a trial of Housing First in Canada demonstrated promising effects with respect to housing stability for youth with poorer outcomes in other domains such as employment [8,9].Another promising housing stabilization approach for youth is seen in "Family Reconnect", which emphasizes shelter diversion and mediation, as supports in this instance are wrapped around youth residing with a parent or other family member.
Other work has focused on critical time interventions, as there is evidence emerging that intensive, comprehensive support at the time of transitions into housing may improve outcomes [10,11].One of the most consistent observations in this literature is that housing is necessary but not sufficient, in and of itself, to stabilize the housing trajectories of youth and support flourishing in major life domains [10,12].In particular, articulation of the specific components of wraparound supports that attend housing for youth remain unclear in this field-which some have characterized as being in its infancy [12].A recent scoping review of housing stabilization approaches for youth identified a small and diverse literature comprised primarily of case studies with very limited trial data [13].These papers highlighted factors such as the need for supportive housing provided over longer periods with a range of wraparound supports.Alongside limited detail regarding program components, specifics regarding how these supports were developed, integrated, and sustained were particularly lacking in the reviewed papers.More nuanced commentary in this area can be found in a recent paper by Slesnick and colleagues [12].Along with describing approaches to address basic needs (e.g., negotiating the payment of landlords and bills), they emphasize the need for a flexible approach by support workers in terms of intensity of support and indexing to variable degrees of client engagement.Guidance is also given in the context of Housing First for youth [14] in areas such as assessment and admission processes, emphasizing youth choice and community integration.However, validation of these domains through research and greater specificity in their application remains a gap area.In particular, considering the large amount of diversity across varying urban contexts where youth homelessness occurs, very little is known about how housing supports may differ-having been optimized for city and population-specific requirements.This knowledge gap can hamper implementation without a clear understanding of more universal best practices and which elements need to adapt to site-specific considerations.Working toward the articulation and validation of youth-specific supports might lead to advances in improving access to effective housing services.Such work would draw on the precedent of how the clear articulation of the Housing First model for broader adult populations has led to its garnering a large body of trial evidence and wide implementation internationally.
The present multiple case study investigation was undertaken as an early effort to develop guidance on establishing effective housing stabilization interventions for youth drawing upon diverse, established practice settings.This study presents an opportunity to provide further detail on model components, their implementation, and which components may be cross-cutting and which might differ as a function of factors such as the size of the city.This research also provides an opportunity to compare and contrast observations with the more established adult literature-bridging both implementation and practice model considerations.It is hoped that this work might inform future studies that can establish and validate clear practice standards for the youth housing sector.

Methods
To articulate promising practices in the delivery of housing stabilization interventions for youth, an intrinsic case study approach was employed.As described by Stake [15,16], this involved site selections based on their own merits and uniqueness to better understand a particular case.Approaching the research question with this case study method appeared the best aligned with both the need to address the diverse contexts and populations involved and the early/limited state of evidence.For this study, sites considered leaders in the sector were studied to better understand their approaches to youth housing stabilization.Triangulation was used to enhance the rigor of the design.We examined and compared data collected from a range of organizations (considering geographic location and organization size), different participant groups (i.e., service providers of various programs, service leadership, and service recipients), and data sources (interviews and archival documents).Additionally, detailed case study reports were sent to organization leadership for review and all feedback and comments were incorporated into the final draft.The case studies were intended to provide a "thick description" that would help in fully understanding and experiencing each case study site contributing to the trustworthiness of the findings [16].Ethics approval (#004/2020) was granted by the Centre for Addiction and Mental Health Research Ethics Board.

Site selection and Sampling
To identify housing stabilization study sites, key informants from service, policy, and research sectors were engaged to recommend what they considered to be effective and innovative service settings.This process led to the engagement of the National Learning Community on Youth Homelessness-a community of practice made up of executive leaders of Canadian services in the youth homelessness sector that are national practice leaders.The National Learning Community membership process is invitation only, drawing up organizations that have won national awards and organizations nominated by peers as sector leaders and innovators.The full network was invited to consider participation, being provided with information about the project by email.The intent had been to conduct 5 case studies and a total of 5 sites volunteered to take part (no sites were rejected).The original intent to sample diversity amongst organizations recognized as providing highquality services was challenged due to pandemic pressures, as discussed later in the paper.However, while sampling was opportunistic and, as such, posed a study limitation, a diverse group of organizations were found as a function of organization size and region with some geographic limitations (no representation from Eastern Canada or the Prairies).Another parallel study is underway, employing the same methods, concentrating on organizations with an Indigenous focus broadly and in smaller, northern, urban centers.Within organizations, all senior leaders were interviewed with leaders engaging all staff at the organization working in housing stabilization services with invitations to participate.Service staff, in turn, described the study to individuals and groups of youth residing in their housing services who were subsequently engaged by research staff.

Data Collection
Qualitative data were collected between March 2021 and March 2022 using in-depth interviews.Individual interviews were conducted using a mix of virtual and in-person interviews with service leaders, direct-service staff, and service users, utilizing separate semi-structured interview guides for each group.Domains of inquiry included a detailed history of the trajectory of services developed and offered over time, components and integration of the service models, how resources are generated and leveraged, and position within the local systems.The perceived "theories of action" of the participants regarding how their activities lead to outcomes were also examined.The interview questions were derived through discussions with service leaders in the sector with respect to important domains and knowledge gaps.Being mindful of the small number of participants per organization and potential confidentiality concerns, limited demographic information was collected and reported.The duration of the interviews ranged from 40 to 60 min.Interviews were conducted and recorded, then transcribed verbatim by T.d., O.D., and J.J.In addition to these semi-structured interviews, archival documents from each organization were requested and reviewed (e.g., annual reports).

Data Analysis
Data were analyzed jointly by S.K., O.D., T.d., and J.J. using NVivo 14 software.We used the circular approach to analysis as described by Crabtree and Miller [17].All transcripts were read to develop an overall sense of the data collected.The main objective of the analysis was to synthesize the various key informant interviews (including the service recipient (youth) and service providers (staff)) and secondary data to produce a narrative account of the diverse housing stabilization support models in Canada.This included a description of what made them practical, detailed information about the services these programs provide, how they operate, and how they were implemented and sustained.The analysis employed a constant comparative analysis [18] entailing a sequence of open coding to identify and apply provisional codes to similar portions of transcribed data that re-occurred or appeared to be emerging as significant; thematic/focused coding to establish categories of responses, grouping them into emerging themes; and theoretical coding to identify how various themes inter-relate.
For quality check and inter-coder reliability, all transcripts independently coded by T.d. and O.D. were later reviewed for accuracy by researchers T.d., O.D., J.J., and S.K. Preliminary themes were discussed with the research team and then regularly reviewed in an ongoing analysis.For the coding of documents, a similar process unfolded.Documents were coded within Excel 2024 software using the same coding steps and scheme as above and then reviewed by members of the research team.These procedures, extending to the preparation of the manuscript, sought to ensure that the quotes provided were representative and divergent perspectives were brought forward when possible.

Results
In total, data were collected from (1) organization service providers and leaders (n = 26); (2) service users (n = 35) with an average of 5 service providers interviewed (range of 4-7) and 7 service users (range of 3-12) at each site; (3) and a variety of organizational documents and publicly available resources (e.g., organization websites).The most recent annual reports at the time of review from each organization, as well as a mix of program plans, fidelity reports, surveys, and strategic plans shared by sites were included in the documents.The quotes provided throughout the paper consisted of 17 different service provider and leadership participants and 10 different service user participants with all five case study sites being represented.Service provider and organization leadership participants ranged across roles and experience.For service users, there was an effort to interview participants across a variety of programs within each site.The five case study sites were located across British Columbia and Ontario; ranged in organizational size; and demonstrated decades of housing stabilization services for youth (Table 1).The five case study sites had a variety of models, scale, and levels of support, providing a unique and ranging perspective on stabilization models within Canada (Table 2).The findings across case study sites were quite consistent, and as such, the results were presented together to highlight the significant themes across sites while noting specific points where themes diverged as a function of a given site.The results below represent the thematic analysis of three main areas; (1) Models of support-specific components and cross-cutting themes, (2) Support development, integration, resourcing, and (3) Perceived challenges.This organization of results was designed to facilitate a comparison with the literature on youth-specific and adult sector models of wraparound support as well as Housing First implementation best practices.

Models of Support-Components
Across all sites, supports designed to complement housing were provided in some form, either in a general or specialist role, in areas of mental health, education, employment, physical healthcare, life skills, and basic needs (for a detailed breakdown see Table 1).General wraparound supports would often involve a case manager or youth worker providing direct one-to-one support and connecting clients to community-based resources.Within some organizations, more specialist, or professionally specific supports were provided in the housing setting or other organization spaces.These specialized programs were seen to reduce historical barriers that are often faced and increase access to support in key life domains.Four of the organizations had a mental health program and/or counsellors employed, and two provided on-site access to primary healthcare.Service users noted that having an on-site mental health program was important in reducing stigmatization and increasing accessibility.
"So that having it in the building. . .You don't feel embarrassed and then mental health.When you're homeless, there's a lot of mental health issues.You don't have help.Like I can verify for that.Like I kind of ignored it and that's why I went down the drug path.So to have it here and be like, 'Hey, like I'm having a bad day'"-Service User Other examples included having on-site employment programs or specialists on staff (three organizations).Staff spoke about how these dedicated programs may support youth to navigate barriers that have historically blocked paths to securing employment."We've recently started up a youth specific employment services for youth with more barriers.So youth who have mental health or other challenges that have historically prevented them from securing employment, can work with employment specialists at -) to look forward and be supported in finding employment."-Staff The importance of increasing access and reducing barriers were also heavily emphasized in the area of education.The most prominent example of this was one organization providing a classroom and teacher that youth could access on-site with support from a professional educator "-has a classroom within our building so youth can get support from a fulltime teacher that sits in that classroom for the online pieces.Each youth is working on their own classes, but the teachers in the room to support them and then we'll have a graduation."-StaffAll organizations emphasize the value of these specialized supports and on-site resources in promoting access and gains in key life domains beyond general youth worker support roles that touch on a number of areas.

Cross-Cutting Principles-Flexibility
A key process factor that youth, staff, and leadership highlighted across sites was the ability to deliver flexible services.The idea of flexibility occurred across many different areas of service delivery, including length of services, varied combinations of supports, and decision-making based on the unique needs of youth rather than rigid guidelines.
One dynamic of flexibility was the duration of available supports and housing programs.Both staff and youth discussed how not having a firm move-out date or being able to maintain contacts with the organizations after they exited the program created a natural transition into the next stage while still maintaining a sense of security if needed.
"But for me right now I think I just want to stay here for a little while longer just because at least here like there's always someone I can reach out to, I'm not like-I don't know if I'm ready to be like 100 percent independent yet.But it is nice to have those options and it's also nice to know that I can also stay if I want to"-Service User Additionally, offering a variety of supports and having programming that was choicebased was described as key.Maintaining model fidelity is important for structure and effective service delivery, yet also having opportunity for different levels and types of support was described as the optimal practice.Incorporating flexibility in service offerings is significant as it promotes individualized supports.
"So I think they, they're really good at like fitting to everyone's needs if they need something.So yeah.they're really good at that."-ServiceUser ". . .a huge benefit for them is that we're not some institutionalized thing who plans their everyday, plans their every minute, tells them where to go, how to eat, what to eat, how to do"-Staff Lastly, flexibility appeared within the leadership decision-making level.Leadership flexibility was described as making it easy for direct-service staff to work with youth in a way that was individually tailored.Size of the organization also played a role in flexibility, as larger organizations may have more ability to create a range of housing programs but, conversely, smaller organizations may have fewer funders to answer to in designing services.
"But I, again it does give you some flexibility, right, so the one thing is would say is being larger it means we do have flexibility we can do things like, we're going to create a queer building.But as a smaller organization, and I've worked in those too, you just, you're so strapped all the time, right"-Leadership "Some of the elements that really have helped [. . .] thrive are the fact that we are able to be so flexible to meet the needs of youth, right.It's not an organization that likes to say no.That being said, we do when it's kind of like a safety risk or a youth or staff, other youth, that kind of thing.But for the most part, [. . .] really has a lot of leeway to make the decisions that they feel would be best for youth and for staff "-Staff

Cross-Cutting Principles-Intensive Youth Engagement
A key factor in the design of relevant, inclusive, and safe housing service environments was the promotion of youth engagement.Through councils and committees, youth are able to organize with peers to provide input on programming design and service delivery.Additionally, incorporating youth-led roles within programs created a dynamic where youth can connect with peers who have shared lived experience.Youth also spoke of these positions as an opportunity for leadership and growth as they transition into adulthood.
"I advocate for the other tenants too that live here, and so I advocate for better access to resources and better communication, stuff like that.Other things that we need.I advocate for our need for safety, I advocate for some of our wants, some of the things that make us uncomfortable, like the giant banners on the front of the building, that's what we're currently working on trying to get rid of."-ServiceUser "And in exchange for free rent, they're on site, they get trained through our peer support program, in various helping skills, boundaries, this that the other thing and they provide some on site monitoring and support to the individuals that are residing there."-Leadership

Cross-Cutting Principles-Equity, Diversity, and Inclusion
Another emphasis in the area of youth engagement centered on Equity, Diversity, and Inclusion.Across sites, an EDI strategy was underway at multiple levels of organizational design and service delivery.Both service users and staff discussed implementing EDI through areas of representation, partnerships, programming, training, and specific diverse housing settings.Rigor in this area was emphasized, given the diversity of the youth being supported."40% of the youth at-are younger than age 19, 23% identify as LGBTQ2S+ and 23% identify as Indigenous."[Document Source] One domain in which sites looked to improve in areas of diversity and inclusion was through more representative staff and roles.Having staff and positions that reflected those that the organization was serving assisted understanding between staff and youth.
"We also have a cultural wellness worker who works 20 h a week.And her role is to provide an Indigenous lens to our program and work specifically with Indigenous youth or any other youth that are interested in. . .involving those practices into their recovery journey."-Staff"What I feel that if-had a more diverse cultural staff team, it would be so much helpful. . .because interpretation is not only language, it can be values, how the person is raised."-StaffFurthermore, several specific practices were implemented throughout organizations to offer diverse cultural and identity programming.This created spaces for youth to feel connected and understood within their housing.
"And then on Fridays, we always-we usually do, if there any Indigenous workers here, we do like-what's it called-smudging.We'll have like a group, kind of we'll sit around the fire and do like cultural stuff."-ServiceUser "We also have a gender specific group for women and people who identify as female that does that same sort of work and convenes regularly.And also, locally we have like the queer youth group that meets and also an advisory committee that's convened around youth who have received service"-Staff Organizations also looked to address diversity and inclusion through a purposeful redesign of programs that focused on increasing acceptance of gender-diverse and transgender youth.
"Another shift, so, a lot of shifts have happened in the last few years.So, I mentioned that our homes used to be called the boys' house and the girls' house.They're now the male identifying house, female identifying house, and there's a gender diverse house that's . . .intentionally kind of open and without any barriers there"-Leadership Lastly, organizations spoke to the development of trainings and frameworks to increase staff and organizational understandings of EDI; however, assessment of the direct impacts on services and outcomes was described as challenging.
"We've done work around EDI work, the last sort of organizational push we did, was to adopt an anti-oppression framework. . .and that was a solid piece of work, but I don't think it really had an impact on the experience of folks, both staff and youth in our services or on our work sites."-LeadershipUltimately, staff and service users spoke to how better representative staff, implementing culturally specific programming, and promotion of acceptance of diverse identities contribute to culturally relevant and safe housing supports.

Data and Evaluation
Budget growth and sustainability strategies were discussed extensively as they related to building out more robust housing stabilization services over time.In terms of building a rationale for funding, themes included using evidence of impact and avoiding sympathyinducing narratives about clients.Data generation was also seen as important to identify system gaps and develop innovative programming that "wouldn't have existed without us."Staff spoke to the importance of utilizing data to obtain funding by providing evidence of proof of concept and positive impacts on other systems, such as healthcare.
"We had a social return on investment study that was done a few years ago on our scattered site housing, which showed that for every dollar in, we got just under $5, back.2.50, to the you know, the emergency care system, and then another two something to the individuals that were housed and some benefit to the, to the landlords that were leasing to us. . .We use that as a document to sell, sell, sell, to try and get resources. . .give me basically one case manager and 20 rent supplements, and we'll take care of 20 of those people that are going to be on the streets.And we'll do it in a way that's cost effective, and you're going to see a return."-LeadershipBeyond securing funding and growing services, data generation was also useful in meeting service users' needs and assessing their goals.This helped with engaging youth on how they are doing in the program while also seeking out improvement areas in service delivery to fit their needs.
"So we have a pretty extensive survey that we created last year.We created it in the spring, and we ask them, we either do the intake-or do the survey with them, some youth like to do it on their own, . . .and we track everything."-StaffGrowth was described as a back-and-forth process, emphasizing building the best possible team, generating evidence of impact, and growing from there rather than placing a sole emphasis on obtaining funds without a strategy.
"Not looking at building your budget, but building the best team possible, and you know, and I found that if you do it right your budget will grow with that."-LeadershipFunders were described as being very responsive to this type of approach-building a model, validating, and then providing more funding to build further based upon successes to date.

Balancing Multiple Funding Sources and Resource Allocation
Organizations described obtaining funding from a range of sources, including philanthropy and all levels of government.Data and relationship-building were described as essential in identifying and cultivating funders-with a rigorous strategy necessary in this highly competitive space.Related to housing stabilization specifically, approaches include securing housing from one source, subsidies from another, and staff supports from others.Tracking and being responsive to such a broad range of funders was, however, described as challenging.More broadly, obtaining and sustaining an adequate amount of funding for an optimal suite of support services was described as a persistent challenge.This challenge, which is very common in the not-for-profit sphere, was compounded for these organizations given the breadth of housing supports provided.
"And the challenge always with funding is that they're very specific, everybody wants very specific things, and often those specific things don't include administration, so you're expected to put all your money towards a project but you need those backend supports to manage them.And we need a very sophisticated finance director to keep track of funding for-we've got 25-plus programs, not necessarily 25 different funders for each, but within each you have-some of them-a huge mix.Like with our housing programs, there is a huge mix from government to private, and they all have a little sliver."-LeadershipAt one case study site, a Youth Reconnect and shelter diversion approach were delivered.The organization's successes in keeping youth within their community of origin and out of the shelter system created a reduction in the organization's shelter use.Although a positive outcome, it was a trade-off where the shelter needed fewer resources and, as a consequence, could secure less funding.This was a challenging negotiation, ensuring that resource reduction in the shelter context was balanced by securing increased resources for youth reconnect programming.
Achieving the right balance of service-related investments and growth, while meeting the requirements of an array of funders and shifts in funding amounts and sources over time, was described as very difficult and risky to the organization if done wrong.Getting this balance right, in contrast, facilitated growth and sustained funding while being effective and staying true to the mission of the organization and ethical practice.Some service leaders described the utility of hiring consultants to assist in developing growth plans given the complexities involved.

Collaboration
Across all sites, collaboration with other agencies, partners, and different community systems were key in generating resources and providing a wide range of support types.Collaboration assisted organizations in creating programs, delivering effective interventions, managing referrals, and enhancing access to supports and culturally responsive programming.
Partnerships with the school system were seen as effective levers to build and implement services.Working with schools, organizations were able to identify and implement early intervention approaches for youth who may be at risk of homelessness.For one organization, this helps to both provide youth with timely services and keep them close to home where known supports can be leveraged to maintain their attachment to their home community.". . .I talked to my teacher at school and they had told me about this program, and then eventually when I did end up leaving when I was 16, my principal immediately got me in contact with a worker from the-so I could start to try and get the ball rolling in order to find myself sustainable housing"-Service User "So, first, we're going to stabilize your housing, and then, second, we're going to look at your attachment to school.Are you still in school?Have you dropped out of school?Have you finished high school?All of those types of things.We also find those school questions help determine what their home community might be, if they've already been moving around or not.Ideally, we're getting to them before they've ever had to leave their home community or home school, because a lot of those more natural supports are already there, and we don't want to lose those."-Staff In creating new programs, one organization highlighted the significance of leveraging local developers with existing builds to secure housing units.With the affordable housing shortage, utilizing unique housing streams has been key in building programs.
"We started talking about the issue of housing and youth housing and what could potentially happen there.And a [local developer] indicated to me that he had a property like a piece of land that he was looking to develop. . .So they're like 300, square feet, and he had this property, he was looking to do a five-story building, all with studio units. . .So, this led to an ongoing conversation about what we might do and resulted in an agreement that we would,-lease one floor of that building with 18 studio units of housing specifically for youth, and we would get that at a reduced rate basically"-Leadership Additionally, organizations looked to leverage partnerships with provincial housing to implement youth-specific programming in an already existing project.Taking advantage of existing programs provided an opportunity to expand housing services and demonstrate good outcomes, building a rationale for further funding.
"But in the absence of other resources, it's basically we've built 35 units in the last year of youth housing versus waiting for the ideal scenario to come along where a piece of land falls out of the sky, the provincial government says, OK, we'll give you enough money to do this.We, we had to make a go of it with the idea that as we can demonstrate that this works, and there's a specific need, we want to leverage this into a standalone experience."-LeadershipThrough the development of relationships and building trust with housing partners, organizations leveraged existing units into new youth housing programs to work around resource availability barriers.From there, organizations can establish evidence of need and effectiveness to leverage into further resources for future projects.
As described earlier in the supports section, the most frequent way collaboration was described through case study sites was to utilize partners to expand supports and provide access to specialists.These partnerships were implemented to bring supports on-site or, if offered at other organizations, service access is facilitated through strategic partnerships.Staff members spoke to the significance of utilizing community partners to meet client needs in key domain areas beyond what they were able to offer in-house.
"We looked to stabilize housing, and then brokerage service.So, we're not offering any kind of clinical support, we're not offering any kind of addiction, we're strictly housing supports.It's a wrap around.So, although we are looking after the housing, we're also the broker.So, if the youth indicates that they want additional services-clinical, or whatever it may be-then we work with our partners to find the service to best address how they're expressing their needs, and then we link them to that service.So that's kind of our broker role."-Leadership"I'm working with -.So, the worker comes to our building, meets with the client in the unit, and works on different life skills or support in attending appointments."-StaffMany staff discussed programs and partnerships that had been created to support diversity.Such partnerships expanded culturally-relevant resources and increased services specifically for racialized and Indigenous youth as they are over-represented in their service contexts."So right now I'm trying to work on a partnership. . .they're a Community Health clinic, but specifically for Black folks.So what can we do-what can we partner with to bring you to do some services specifically with our kids who are, you know maybe looking for that support."-Staff"Our last practicum student created an Indigenous resource database for us, and it's incredible.And so she went to every youth in our organization right now and asked them, what band they were from.And she went and put links to all the websites for those bands."-StaffGiven that youth housing programs and services end at a certain age, the transition to independent living afterward can be challenging due to housing costs and availability.One service user highlighted how leveraging partnerships can assist in securing finances for permanent housing, which is an important factor in long-term housing stability.". . .they're going to help me get my subsidy approved from the city.And they're going to talk to the people about how we can make a plan for last month's rent because it's hard.And they helped me with moving vans and getting me boxes-it's so helpful and it takes a lot of the stress off."-ServiceUser A final way organizations discussed collaboration was utilizing partners to enhance community capacity and understanding by providing resources to and otherwise engaging and educating community groups to reduce stigma and increase acceptance and belonging in community contexts."For the average community person, you know, the idea was we were bussing up criminals from Toronto and everywhere else.And so we had to do a lot of work, a lot of community development work, to sort of, you know, get people on side about what we were doing.I think there were a lot of people that we were able to bring on side and get involved in what we were doing."-StaffThere were challenges experienced within the area of collaboration.With many partners involved, it can create confusion as to who may be responsible for what in the service user's life.Other times, there may be disagreements as to what the best course of action is or competing interests depending on each partner's role."Because our caseloads are big and we're over here now, and then something big happens and we go back and look and say oh, we thought you were doing that.No, we thought you were doing that oh, we don't do that you do that.That kind of stuff comes up, and you never get really, really serious implications, but you know, any sort of bump along the road in somebody's recovery from homelessness is a serious implication."-LeadershipA final takeaway in the area of collaboration was that in order to effectively implement youth stabilization services, collaboration needs to be developed at all levels both within and outside of the organization.Maintaining relationships with funders, the network of partners, and different community sectors brings different growth opportunities and challenges.On a leadership level, collaborating can introduce new funding streams and program development.With direct-service delivery, effective relationships with partners contributed to cohesive implementation of supports for the unique needs of the youth.
"First of all, it's relationships, but it's relationships at multiple levels of the organization.Right.And sometimes it's the service delivery staff on the front line.They get it, they know, they're there, and they're working for the best interest of the young people, and they work pretty well together."-Leadership

Agency Size and Context
While common themes were connected across sites, each organization had their own unique trade-offs and implementation factors based on the context of their location, size, and program design.This area was the greatest point of divergence across sites.
The context of organization location and scale created different implications for the tailoring of services to youth needs.One large organization in a large city was able to maintain a Housing First approach while still offering a variety of unique housing and program options for service users within the Housing First model.This was accommodated as a function of large numbers of units across multiple sites.
"We have the ability to have different types of housing based on different types of need while always maintaining a capacity to move somebody out from a Housing First perspective if those things are required.So, it's a two-pronged approach."-LeadershipFor smaller organizations in mid-sized communities, a different approach was needed to maximize program offerings given fewer resources.One organization utilized smallersized housing sites of approximately eight units which allowed for more indexing to be flexible in designing specialized programs.This smaller-scale form of housing meant that the organization could split their resources in different areas and maximize their ability to meet the unique needs of youth (e.g., an abstinence site and a harm reduction site)."There's a lot of more anecdotal evidence just based on our history that these houses of five, six, eight, are actually quite effective if connected with the right types of resources"-Leadership Although flexibility was highlighted as a key principle, size and contextual factors may impact the ability to implement flexibility within housing models.Funding challenges and small organizations may limit access to spaces to introduce and implement creative, flexible programs as they try to adapt to the limited resources at their disposal.Additionally, the increasing need for affordable housing may make it difficult to extend the duration of support and housing.Furthermore, while being able to modulate program designs to meet individual needs is valuable, there also needs to be adherence to the program model to maintain fidelity and consistency.
Ultimately, the contextual factors of city size, organizational resources, and scale led to organizations implementing and delivering their services in unique ways that they perceived best aligned with community needs.

Challenges
Across case study sites, service users, staff, and leadership highlighted challenges that were faced within organizations.The most common challenge was housing affordability and availability.Both staff and service users discussed long waitlists to enter housing programs and hesitancy or worry leaving housing programs due to the cost of market rent housing."But, like I said, some of the room rentals are $800 a month now, and that's more than their entire Ontario Works cheque here.So, in making sure that we're able to find safe, affordable housing and not-I'll use the word a sketchy rooming house or something like that for, you know, maybe a 16-year-old girl who's never lived on her own, like, that's definitely an issue."-Staff"Working with a younger population as well some landlords are unsure about housing clients who may be 16, 17 and even 18, maybe still in high school or in university or not in school etc. and just unsure how they were going to house them without a co-signer.So working with the young individuals, typically in the private market landlord to be able to get a co-signer"-Staff Staff discussed specific challenges to their position and role in the organization.Staff noted that burnout and limited compensation had negative impacts on their well-being and job satisfaction.This was a risk for high turnover rates at organizations, leading to disruptions in services and relationships with service users.Some organizations looked to hire more staff and develop policies and programs to better support staff as a way to manage turnover and high burnout rates.
"Because of high caseloads and high complexities of youth, intentional 1:1 time is sometimes missed or the opportunity not taking because of the level of "crisis support" or "firefighting" that can take place.Adjusting caseloads to be more manageable to allow for more intentional case management and relationship building."-DocumentSource "A lot of challenges that we're facing currently, and ongoing I would say, is the turnover of staff because of burnout"-Staff Service users described various challenges and barriers they had experienced within these housing programs.Although organizations had implemented extensive supports, service users still faced long waitlists when accessing external community resources.Additionally, service users discussed that when they did get connected, supports such as counselling, employment, or medical care could be limited in effectiveness due to limited access, inconsistency, turnover, and short length.One service user discussed how this discouraged them from reaching out to further supports, while staff highlighted reliance on informal crisis counselling."So you'll have somebody you' maybe connected with, a doctor or a counsellor and then the next week they're gone. . .I mean like there's no consistency."-ServiceUser "No [they didn't help], I had to find [the job] myself.Like the stuff they offered is underpaid"-Service User Another significant challenge that some service users experienced was interpersonal safety within the buildings where they lived.Service users reported experiences of violence and confrontations in the building, guests entering the building leading to conflict with other residents, or apartment takeovers.Service users also noted an increase in these safety issues during off-hours and in the evenings when staff were not present.In response to these challenges, youth proposed several solutions such as disciplinary actions, increased security/staff presence after hours, and educating residents on appropriate and safe conduct.Although not every case study site detailed similar challenges, programs with larger buildings and a mix of needs reported more problems in this area.
"OK, so a typical example, would be a young person who's vulnerable.So they've been exploited in the past or trauma.They have PTSD, or what have you multiple concurrent disorders.So they get housed.So they have apartment, and then they feel bad for their friends who are homeless.So they have them, yeah, you couldn't come crash at my place.And then they let them in.And then next thing there's a takeover.It could be-we don't have tactile proof, but it's pretty obvious that sometimes it's gangs.And they do human trafficking."-Staff"So, it's pretty often here that we have someone banging and screaming on doors and fights in the hallway.There's a lot of scary, sketchy things that happen, especially late at night and that concerns a lot of people, and it makes a lot of us feel pretty unsafe."-ServiceUser Working relationships between staff and clients were also difficult at times.Service users that perceived staff to treat their role simply as a job or as not having similar lived experiences spoke of difficulties with relationship building.Some staff also detailed a lack of diversity amongst service providers as impacting their ability to engage diverse clients.Furthermore, service users' relationships with each other was also a common challenge.Conflict between service users with differing needs and expectations could yield negative exits and experiences in programs.". . .everyone here just kind of feels like they're punching the clock or just got out of university or whatever.I don't know it's just-the other guy that I talked to, he's like from the streets and been to the lower east end, and I used to live on the lower east end so we have kind of like a bit of a connection."-ServiceUser Issues with building maintenance and appearance were also a challenge.Damage to units was not uncommon with repairs being a significant expense for agencies.Funding challenges affected both building maintenance and overall quality-with implications for youth experiences."It's kind of like stigmatizing, people drive up to the apartment building and like what is this . . .like a hospital or something-no it's just an apartment building . . ."-Service User "And so, the cost of turning the units between tenants was also really, really growing.And so, it became pretty apparent that our facility management when it comes to nonprofit buildings, was pretty weak. . .Because young folks, I mean the buildings weren't attractive, they weren't welcoming, they weren't nice spaces to be in and looked fairly neglected."-LeadershipA final challenge that was experienced by organizations was community pushback.When programs were first being developed, there could be discrimination against individuals who have experienced homelessness or used drugs and organizations would face attempts to shut down the program.
"But the community in -, where-is located really pushed back against that model.And we ended up with like a petition of 14,000 signatures from residents saying we don't want this here.And that was really hard.Like, I went to the open house at the community center and it was just full of really upset, angry folks who did not want to see this building."-Staff

Discussion
This multiple case study project was designed considering extensive evidence that housing alone is necessary but not sufficient to support youth in permanently exiting homelessness and flourishing in major life domains [12,19].Furthermore, this study helps to address a gap in the literature where housing stabilization and wraparound supports are often thinly described both in terms of program components and implementation with minimal consideration of how support models index as a function of city and population characteristics [12,13].
At a high level, these case studies suggested a good alignment with the core values of supportive housing models such as Housing First for youth and adult populations.Specifically, there was an emphasis on tailoring services to youth choice and individualized needs, positive development in key life domains, social connectedness, and community integration [14,20].The components of these models of support in the form of case management, health and social service connections, employment and education supports, independent living supports, and connections to community are all likewise consistent with supportive housing best practices [14,20] and elements identified in the broader youth housing literature [13].
Several of the findings of the present study, going beyond more generic descriptions of values and practices, might speak to both youth-specific considerations and optimized service effectiveness.These findings speak to organizations engaging education, employment, and health specialists to provide on-site services as much as possible.The strong emphasis on education is less evident in the adult supportive housing literature and, no doubt, reflects the unique needs of youth populations.Future work may generate evidence behind the strength of specialist, embedded supports (vs.generic case management and external referrals) and resonates with other complex intervention evidence bases such as Assertive Community Treatment for adults with mental illness [21].Additionally, the Family Reconnect emphasis in these case studies represents another youth-specific support component, with family conflict being a primary driver of homelessness for youth [22].
The strong emphasis on the flexibility of service types, intensity, and duration align with supportive housing best practices [14,20].The theme of this flexibility extending to the approach of organization leadership, in maximizing staff autonomy and their ability to individualize supports, was not commented on substantively in the supportive housing literature.The utility of flexible leadership is, however, addressed in the broader healthcare literature with a particular focus on complex and dynamic care contexts [23].Similarly, the youth engagement and equity domains identified here align with supportive housing best practices.The intensity of focus on these areas (e.g., extending well beyond simply having advisories, working toward whole organization anti-oppression frameworks) may be another signal of a best practice area warranting further study.Indeed, highly intensive youth engagement is increasingly being emphasized as a best practice cornerstone in a range of service contexts [24,25].Also, previous work in the area of youth homelessness has highlighted how fundamental and essential the depth of approach to equity considerations is in this field (e.g., 2SLGBTQ+ youth) [26].
The themes generated in these case studies in the implementation frame are largely in line with implementation guidance in the Housing First literature [27].It was evident in both coverage of strategies and challenges, that cultivating supportive team environments with extensive opportunities for training and mentorship is a priority.A priority and also an area of difficulty is an underfunded sector engaged in very stressful work where retaining a healthy workforce is difficult [28].Furthermore, at the program leadership level in our case study sites, work had been conducted to establish clear objectives and well-articulated practice models which were continuously evaluated and iterated upon.Leaders seemed highly engaged and supportive of staff.At the system level, interagency partnerships were clearly present.All of these characteristics are present in descriptions of Housing First implementation standards [27].
Where the present findings make a unique contribution is, again, on emphasis and nuance.For example, although collaboration with complementary organizations is a supportive housing practice standard and has received some comment in the youth homeless literature (primarily grey literature; [29]), the emphasis on a wide range of collaborations for multiple purposes was striking.Functions of these collaborations included an enhanced ability to provide access to specialist supports on-site and off, providing culturally relevant services, the creation of housing units working with developers and government, fostering community engagement to reduce stigma, and creating opportunities for prevention through collaborations with schools.In resource-constrained contexts and in the interest of meeting the needs of a very diverse population of youth, collaborations had implications for organization growth and viability, sustaining a focus on a core mission, and improving the quality and breadth of services.These efforts resonate with the literature on the means to work against community resistance to the presence of these types of services and creating opportunities for inclusion [30].
The other theme that has not been emphasized extensively is that of developing rigorous data infrastructures.Employing data effectively can help to focus interventions, guide decision-making about service models and expansion, and help to build a rationale for more successful fundraising.The final point that arose in these case studies that has received minimal attention in supportive housing literature is the manner in which growing and sustaining high-quality housing supports for youth is a balancing act.This theme was a major emphasis across leadership interviews and, while resonating with generic senior management best practices in areas such as healthcare [31], resource and priority balancing are arguably all the more essential in youth housing stabilization-where a complex intervention meets a diverse population with complex needs.Key points of balance included those of (i) keeping organization focus and cohesive teams through growth periods, (ii) balancing the resourcing of prevention while reducing an emphasis on shelter-based supports, and (iii) weaving different funding sources with different support facets in a coherent manner.The specific city context can influence these growth and model determination processes, with there being some advantages to being a large organization with large facilities and some advantages to being smaller (e.g., more and smaller housing sites that target specific needs such as tailoring to those using drugs and those engaged in abstinence).Awareness of the contextual factors of city size, organizational resources, and scale is key to developing a model that best fits the community's needs.
This study brought forward several implications for future directions in the field.First, this study could contribute to the development of more detailed descriptions of best practice housing stabilization supports for youth and their implementation.More nuanced practice guidance, and attendant tools for assessing program fidelity, could improve practices and deepen the evidence base.Some efforts are underway in this regard, such as the Making the Shift Housing First for Youth program of research [32].Such work might also benefit from connecting with the best practice literature in areas such as supported employment and education [33,34].Second, attending to the priority of providing services flexibly, there is a tension in navigating the maintenance of model fidelity while also being flexible to the unique needs of youth and of the agency.Continuing to unpack what components of these models need to be more uniform as drivers of positive outcomes and what can be modified as a function of needs and agency context is a useful area for future research.Such work might draw on research into modifications to the adult Housing First intervention for Indigenous populations [35].Finally, the manner in which these interventions exist in a larger system has serious implications for the functioning of these models.Given the lack of affordable housing as well as housing processes that often come with barriers of discrimination for this population, youth are left with few housing options to exit into when they transition out of supportive housing.These issues, combined with a largely disorganized and inadequate funding environment, leave even high-functioning organizations struggling to maintain an adequate amount of high-quality, safe, and sufficiently staffed housing.This resourcing problem opened up a tension in our findings between the intent to deliver on these housing stabilization models and the ability to fully and consistently do so.It was intent vs. practice discrepancies, when perceived, that were at the heart of the challenges described in this study-particularly from direct-service staff and youth perspectives.
This study has a number of limitations.First, it was conducted during the COVID-19 pandemic.This circumstance led to fewer interviews across organizations, particularly with service users, than would be ideal.This challenge was mitigated to some extent by the focused nature of the inquiry and the cohesion of themes between sites, which afforded saturation.Gaps in the depth of inquiry in certain areas, nonetheless, are present (e.g., more nuanced information regarding the details of decision-making in the development of services over time could have been helpful; more detail regarding the development and maintenance of EDI strategies and attention to some gap areas such as services for racialized youth).The pandemic also had implications with respect to the original intent to use a rigorous Delphi method to identify organizations willing to participate given the extreme challenges this sector faced.This problem was offset to some extent by the success with engaging diverse organizations and their engagement through the National Learning Community on Youth Homelessness.Finally, this study cannot address the specific outcomes of these programs with our being unable to tie practice elements to effects and assess fidelity of future work, employing pragmatic, complex intervention trial designs can assist with articulating effectiveness, including cost-effectiveness.Some work in this area is underway [36][37][38].

Conclusions
This study of housing stabilization models for youth exiting homelessness has shown a good degree of consistency with more established adult-focused supportive housing values, practices, and implementation strategies [20].Services are flexible, tailored, have a positive/recovery focus, and emphasize social and community engagement.Likely youthspecific and youth sector service quality indicators include on-site specialist engagement, degree of flexibility including leadership flexibility, and the degrees of youth engagement and attention to equity and culturally responsive supports.Points of best practice alignment in implementation included an emphasis on staff training and support, mission and model clarity, engaged leadership, and broader system engagement [27].Again, potentially anchored to youth-specific services and quality therein, we found a marked depth of community partner engagement, the emphasis on data generation and service iteration, and a tricky balancing of resourcing, innovation, and model adherence.These characteristics align well with the demands of complex intervention deployment for highly diverse populations (with youth populations having the added dimension of development in their complexity).This information is important in the context of a service delivery context lacking a substantive evidence base and where platforms are emerging (e.g., A Way Home Canada) that can help to reduce the reliance on duplicative, disconnected, and wasteful trial-and-error approaches.Such work is needed to improve the likelihood that young people transitioning away from extensive histories of violence exposure and systemic adversity can take full advantage of the stability that a roof and a key provide-to heal and have fulfilling lives after homelessness.

Table 2 .
Housing services overview.