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Gabet M, Armoon B, Meng X, Fleury MJ. Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review. Am J Emerg Med 2023; 74:1-8. [PMID: 37717467 DOI: 10.1016/j.ajem.2023.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023] Open
Abstract
Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.
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Affiliation(s)
- Morgane Gabet
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada; Département de Gestion, Evaluation et Politique de Santé, Université de Montréal, Montréal, Canada
| | - Bahram Armoon
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada
| | - Xiangfei Meng
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada
| | - Marie-Josée Fleury
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada; Département de Gestion, Evaluation et Politique de Santé, Université de Montréal, Montréal, Canada; Department of Psychiatry, McGill University, Montreal, Canada.
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Weightman AL, Kelson MJ, Thomas I, Mann MK, Searchfield L, Willis S, Hannigan B, Smith RJ, Cordiner R. Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis. CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1329. [PMID: 37206622 PMCID: PMC10189499 DOI: 10.1002/cl2.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority. Objectives To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact. Search Methods We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies. Selection Criteria We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation. Data Collection and Analysis We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data. Main Results We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings. Case Management and Housing Outcomes Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches. Case Management and Mental Health Outcomes The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817). Case Management and Other Outcomes Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment. Case Management Components For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services. Characteristics of Persons Experiencing Homelessness No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3. The Broader Context of Delivery of Case Management Programmes Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice. Cost Effectiveness The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed. Authors' Conclusions Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.
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Affiliation(s)
| | - Mark J. Kelson
- Department of Mathematics and Statistics, Faculty of Environment, Science and EconomyUniversity of ExeterExeterUK
| | - Ian Thomas
- Wales Institute of Social and Economic Research and Data (WISERD)Cardiff UniversityCardiffUK
| | - Mala K. Mann
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Lydia Searchfield
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Simone Willis
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Ben Hannigan
- Mental Health Nursing, School of Healthcare SciencesCardiff UniversityCardiffUK
| | | | - Rhiannon Cordiner
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
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Mitchell RJ, Karin E, Power J, Foung H, Jones N, Nielssen O. Health service use and predictors of high health service use among adults experiencing homelessness: a retrospective cohort study. Aust N Z J Public Health 2022; 46:896-902. [PMID: 36190205 DOI: 10.1111/1753-6405.13302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the characteristics and cost of health service use of a cohort of 2,140 people attending homeless hostel clinics, and identify predictors of high health service use and time to readmission. METHOD A retrospective cohort study of 2,140 adults who attended a homeless hostel clinic and were hospitalised in New South Wales (NSW) using linked clinic, health and mortality data from 1 July 2008 to 30 June 2021. Multivariable logistic regression examined predictors of high health service users. RESULTS There were 27,466 hospital admissions, with a median cost of A$81,481 per person, and a total cost of A$548.2 million. Twenty per cent of the cohort were readmitted within 28 days and 27.4% were classified as high users of health services. Factors associated with high use were age ≥45 years, female (AOR: 1.52; 95%CI 1.05-2.22), the presence of a mental disorder, substance use disorder (AOR: 1.36; 95%CI: 1.03-1.82), or if the person had been homeless for >1 year (AOR: 1.31; 95%CI: 1.06-1.62). Conclusions and implications for public health: The high health costs generated by homeless adults confirm the need to develop models of supported housing with a focus on integrated care, improved referral pathways and better coordination with community-based support agencies.
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Affiliation(s)
- Rebecca J Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, New South Wales
| | - Eyal Karin
- Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, University of Sydney, New South Wales
| | - Joseph Power
- South Western Sydney Local Health District, New South Wales.,Faculty of Medicine and Health, The University of Sydney, New South Wales
| | - Hayden Foung
- Sydney Local Health District, Concord Centre for Mental Health, New South Wales
| | - Naidene Jones
- School of Nursing, Faculty of Health, University of Technology and Science, New South Wales
| | - Olav Nielssen
- Faculty of Medicine, Health and Human Sciences, Macquarie University, New South Wales
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Miler JA, Foster R, Hnizdilova K, Murdoch H, Parkes T. ‘It maybe doesn’t seem much, but to me it’s my kingdom’: staff and client experiences of Housing First in Scotland. DRUGS: EDUCATION, PREVENTION AND POLICY 2022. [DOI: 10.1080/09687637.2021.1926429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Joanna Astrid Miler
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Rebecca Foster
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Kristina Hnizdilova
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Helen Murdoch
- Homelessness Services, The Salvation Army, Glasgow, UK
| | - Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
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Lavergne MR, Loyal JP, Shirmaleki M, Kaoser R, Nicholls T, Schütz CG, Vaughan A, Samji H, Puyat JH, Kaulius M, Jones W, Small W. The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada. BMC Health Serv Res 2022; 22:477. [PMID: 35410219 PMCID: PMC8996395 DOI: 10.1186/s12913-022-07759-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/07/2022] [Indexed: 01/02/2023] Open
Abstract
Background Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type. Methods We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8. Results Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs. Conclusion Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07759-z.
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Affiliation(s)
- M Ruth Lavergne
- Department of Family Medicine, Faculty of Medicine, Primary Care Research Unit, Dalhousie University, 1465 Brenton Street, Suite 402, Halifax, NS, B3J 3T4, Canada.
| | - Jackson P Loyal
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada.,BC Centre for Disease Control, Vancouver, BC, Canada
| | - Mehdi Shirmaleki
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - Ridhwana Kaoser
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - Tonia Nicholls
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,Department of Psychology, Simon Fraser University, Burnaby, BC, Canada.,BC Mental Health and Substance Use Services, Vancouver, BC, Canada
| | - Christian G Schütz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,BC Mental Health and Substance Use Services, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Adam Vaughan
- School of Criminal Justice and Criminology, Texas State University, San Marcos, TX, Canada
| | - Hasina Samji
- BC Centre for Disease Control, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Joseph H Puyat
- Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Megan Kaulius
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - Wayne Jones
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - William Small
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.,BC Centre on Substance Use, Vancouver, BC, Canada
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6
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Onapa H, Sharpley CF, Bitsika V, McMillan ME, MacLure K, Smith L, Agnew LL. The physical and mental health effects of housing homeless people: A systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:448-468. [PMID: 34423491 DOI: 10.1111/hsc.13486] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/26/2021] [Accepted: 06/07/2021] [Indexed: 05/25/2023]
Abstract
Housing is a significant determinant of health and is widely accepted as a key solution to address some of the health disparities that exist among the homeless. It is estimated that 150 million people worldwide are homeless, and approximately 1.8 billion lack adequate housing. However, understanding of how housing has a positive impact on the health of the homeless remains unclear and underdeveloped. This systematic review investigates intervention studies that report on the physical and mental health effects of housing homeless persons. A search of PubMed, PsycINFO, EBSCOHost-Academic Search Complete and the Cochrane Library was conducted for peer-reviewed articles published in English from 1999 to 2020 that had a combination of at least one housing intervention and health outcome, with a homeless sample. Three previous reviews and 24 studies were included for analysis. Most of the studies (n = 20) encompassed permanent supportive housing interventions that emphasised placing homeless people with mental illness directly into affordable housing with access to support services. The primary health outcomes reported were general physical and mental health, well-being, and quality of life. Despite inconsistent findings and significant issues identified in the reviewed literature, housing (in the short term) improves some aspects of health in homeless populations with human immunodeficiency virus, anxiety and depression.
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Affiliation(s)
- Hebaat Onapa
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Christopher F Sharpley
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Vicki Bitsika
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Mary E McMillan
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | | | - Lee Smith
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Linda L Agnew
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
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Kelleher KJ, Famelia R, Yilmazer T, Mallory A, Ford J, Chavez LJ, Slesnick N. "Prevention of opioid use disorder: the HOME (housing, opportunities, motivation and engagement) feasibility study". Harm Reduct J 2021; 18:112. [PMID: 34749744 PMCID: PMC8576969 DOI: 10.1186/s12954-021-00560-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/19/2021] [Indexed: 11/24/2022] Open
Abstract
Young adults experiencing homelessness are at high risk of opioid and other substance use, poor mental health outcomes, exposure to trauma, and other risks. Providing access to stable housing has the potential to act as a powerful preventive intervention, but supportive housing programs have been studied most often among chronically homeless adults or adults with serious mental illness. The Housing First model, which does not precondition supportive housing on sobriety, may reduce drug use in homeless adults. In the present study, we piloted an adapted model of Housing First plus prevention services that was tailored to the needs of young adults (18–24 years) experiencing homelessness in the USA. Preventive services were added to the Housing First model and included youth-centered advocacy services, motivational interviewing, and HIV risk prevention services. This model was piloted in a single-arm study (n = 21) to assess the feasibility, acceptability, and initial efficacy of a Housing First model over a 6-month period in preparation for a larger randomized trial. We use repeated measures ANOVA to test for changes in alcohol and drug use (percent days of use; alcohol or drug use consequences), housing stability, social network support, and cognitive distortions over 6 months of follow-up. A total of 17 youth completed the study (85% retention), and a high proportion of youth were stably housed at 6-month follow-up. Participation in intervention services was high with an average of 13.57 sessions for advocacy, 1.33 for MI, and 0.76 for HIV prevention. Alcohol use did not change significantly over time. However, drug use, drug use consequences, and cognitive distortions, and the size of youths’ social networks that were drug using individuals decreased significantly. The Housing First model appeared to be feasible to deliver, and youth engaged in the supportive intervention services. The study demonstrates the potential for an adapted Housing First model to be delivered to youth experiencing homelessness and may improve outcomes, opening the way for larger randomized trials of the intervention.
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Affiliation(s)
- Kelly J Kelleher
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, 130 Campbell Hall, Columbus, OH, 43201, USA.
| | - Ruri Famelia
- Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Tansel Yilmazer
- Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Allen Mallory
- Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Jodi Ford
- College of Nursing, The Ohio State University, Newton Hall, 1585 Neil Avenue, Columbus, OH, 43201, USA
| | - Laura J Chavez
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, 130 Campbell Hall, Columbus, OH, 43201, USA
| | - Natasha Slesnick
- Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
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8
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Kerman N, Polillo A, Bardwell G, Gran-Ruaz S, Savage C, Felteau C, Tsemberis S. Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review. Drug Alcohol Depend 2021; 228:109052. [PMID: 34601279 DOI: 10.1016/j.drugalcdep.2021.109052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First. METHODS A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use. RESULTS A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work. CONCLUSIONS Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.
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Affiliation(s)
- Nick Kerman
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada.
| | - Alexia Polillo
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada; University of Toronto, Department of Psychiatry, 250 College Street, 8th Floor, Toronto, Ontario, M5T 1R8, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, V6Z 2A9, Canada; University of British Columbia, Department of Medicine, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sophia Gran-Ruaz
- University of Ottawa, School of Psychology, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, Ontario, K1N 6N5, Canada
| | - Cathi Savage
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Charlie Felteau
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Sam Tsemberis
- Pathways Housing First Institute, 1328 2nd Street, Santa Monica, CA, 90403, United States
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9
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Moledina A, Magwood O, Agbata E, Hung J, Saad A, Thavorn K, Pottie K. A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1154. [PMID: 37131928 PMCID: PMC8356292 DOI: 10.1002/cl2.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
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Affiliation(s)
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada
| | - Eric Agbata
- Bruyere Research Institute, School of EpidemiologyPublic Health and Preventive MedicineOttawaCanada
| | - Jui‐Hsia Hung
- Faculty of Medicine, School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
| | - Ammar Saad
- Department of Epidemiology, C.T. Lamont Primary Care Research Centre, Bruyere Research InstituteUniversity of OttawaOttawaCanada
| | - Kednapa Thavorn
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
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Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review. LANCET PUBLIC HEALTH 2020; 5:e342-e360. [PMID: 32504587 DOI: 10.1016/s2468-2667(20)30055-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries. METHODS We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. FINDINGS Our search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1·13 [95% CI 1·01-1·26]) and high support needs (RR 1·42 [1·19-1·69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8·58 days; p<0·004), whereas the effects on mental health and employment outcomes were unclear. INTERPRETATION Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes. FUNDING Inner City Health Associates.
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