Critical Ingredients and Mechanisms of Intensive Home Support for People With Severe Mental Illness According to Clients: A Qualitative Study on What Works and How, Using a Realist Evaluation Framework

Introduction: Intensive home support (IHS) is a contemporary, innovative outreach approach in the supported housing sector designed to meet the growing need for community living initiatives for people with severe mental illness. Unlike regular outreach, IHS provides 24/7 accessible staff, numerous support hours, and several facilities supporting independent living, including daily activity programs. IHS has not been evaluated before. As the first IHS study, we aimed to identify the critical ingredients for IHS according to clients and unravel how it works.

Methods: We used a longitudinal qualitative design with semistructured interviews after recruiting a purposive sample of IHS clients after 1 year of their recovery journey. Utilizing a realist evaluation approach based on CAIMeR theory and thematic analysis, we explored clients’ perspectives on the impact and key components of IHS.

Results: A total of 42 clients participated in this study, with 32 remaining involved after 1 year. Thematic analysis identified five critical ingredients experienced by IHS clients, including: (1) working alliance; (2) autonomy; (3) relationships; (4) mental and physical health; and (5) housing and living environment factors. The results also highlighted how IHS works and under what conditions, namely, by highlighting trust, continuity, recognition, belonging, and self-confidence. Clients viewed these components as crucial, collectively empowering them toward independent living and recovery. The 24/7 accessibility of trusted support workers increased clients’ self-confidence, although actual use was infrequent.

Conclusions: This study indicated that with IHS, more formerly residential SH clients with severe mental illness can live independently despite experiencing a sense of insecurity and feelings of loneliness. These elements collectively position IHS as an innovative approach to complement existing services, offering valuable support to enhance the independence of individuals with severe mental illness.