Case management and preventive services among infants from low-income families

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

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.

Epidemiology of Child Developmental Problems: The Extent of the Problems of Poor Development in Children from Deprived Backgrounds

The causes of negative child outcomes need to be reconceptualized in terms of the effects of multiple risks. This paper reviews the extent of the problems associated with adverse development in children from deprived backgrounds using two parallel lines of research: epidemiological evidence and early intervention. Epidemiological studies suggest that multiple risk factors interact, magnifying the chances of non-optimal development for at-risk populations. Furthermore, evidence from intervention studies suggests that full-service intervention models are the most effective format for reducing poor developmental outcomes for at-risk children.

Violence prevention in the ED: linkage of the ED to a social service agency

Interpersonal violence continues to be a problem in the United States, most prominent in the inner-city minority young persons population. The medical approach of "treat 'em and street 'em" philosophy has led to foregoing the psychosocial needs of injured young persons. This study describes a program to link young persons who are victims of interpersonal violence to a healthcare system and a social service agency in an effort to meet their psychosocial needs. An unvalidated screening tool was developed by a team consisting of an EP, social worker, and public health scientist to determine the young victims' psychosocial needs. Patients aged 10 to 24 years who were victims of interpersonal violence (excluding child abuse, sexual assault, and domestic violence) were randomly assigned in the study. The control group was given a list of services and the treatment group received an assessment, case management, and referral to appropriate resources. The study site was a community, teaching level 1 trauma center. The study was approved by the institutional review board. Numbers of referrals in both groups were counted and compared using SPSS (version 10, Chicago, IL). One hundred eighty-eight victims of interpersonal violence were enrolled. A total of 82.5% were male, 65.4% were African American and 31.4% were Hispanic. At the end of 6 months, 78 of the 96 young persons (81.3%) in the treatment group made one or more contacts with their case manager and made use of social service, healthcare, and other referrals. Education (21.6%), job readiness (19.1%), and mental health (11.9%) were the most frequently used services. Nine of the 92 (9.8%) in the control group used services; most of these referrals were for social services (7 of 9 respondents) and the others were healthcare-related. The difference in utilization of services between the treatment and the control groups were found to be significant different (95% confidence interval, 1.41-1.55, significance =.00), and there was a strong positive correlation of using services and case management (Pearson coefficient = 0.728, significance =.00). The referral of young victims of violence from the ED to psychosocial services could be successful using a case management model and an alliance between a healthcare system and a social service agency.

Can paraprofessional home visitation enhance early intervention service delivery?

A 1-year randomized trial compared intensive case management (ICM) versus basic case management (BCM) in facilitating early intervention (EI) service use among children in an urban health system. Of 159 participating families with delayed or at-risk preschool-aged children, 88 received ICM from paraprofessionals versus 71 families who received less comprehensive BCM from a nurse. In the ICM versus BCM group, a shorter interval to assessment (98 vs 140 d, p =.05) but similar assessment rate (86% vs 80%, p =.29) was observed. The ICM group had more services recommended per child (1.64 vs 1.16, p < .004) and initiated (1.20 vs 0.85, p < .04). There was no difference in median time to EI program initiation for ICM versus BCM (228 vs 200 d, p = .88) or initiation and visit compliance rate for EI services. Specific efforts to improve outcomes (e.g., decrease initiation time and increase use of EI services) are still needed.

A school-community partnership for at-risk students in Pennsylvania

This four-year, school-community health improvement project addressed fragmentation and under-utilization of services of an at risk population in a county in central Pennsylvania. A population profile was developed that included demographic, attitudinal, and behavioral information as well as information related to liabilities and assets that affect resiliency and decrease or increase the likelihood of academic success. The profile was used in the planning and implementation of risk-reduction strategies that promote a healthy family and, in turn, a healthy community. More than 50 local, state, and national organizations as well as individuals volunteered or provided services at each school. The project produced a 22% increase in parental involvement in school activities; a 15% increase in parental involvement in educational sessions; a 22% increase in volunteers within the school; and a 75% decrease in truancy.

Cost-effectiveness analysis in the nursing literature, 1992-1996

PURPOSE

To review the recommendations by the U.S. Panel on Cost-Effectiveness in Health and Medicine (panel) for use in future nursing research. The review (a) provides a critique of the nursing cost-effectiveness and cost utility literature from the perspective of the recommendations set forth by the panel and other recognized authorities in cost-effectiveness analysis (CEA), (b) constructs an interdisciplinary framework to show the steps in the conduct of CEA, (c) makes the techniques and major findings of nursing CEA studies available and understandable, and (d) offers guidelines for the incorporation of CEA into the evaluation of future nursing intervention and research.

DATA SOURCES

Seven nursing studies published between 1992 and 1996 that compared two or more interventions for costs and outcomes.

ORGANIZING FRAMEWORK

For each study, the (a) perspective, (b) net costs, (c) net effect, (d) analysis of costs and effects, and (e) decision outcomes were analyzed.

FINDINGS

If the panel's recommendations reflect the problems in the health care CEA literature in general, then on balance, the nursing CEA 1992-1996 studies are no more or less flawed than CEA studies in the health or medical care fields.

CONCLUSIONS

Methodologic guidelines and interdisciplinary strategies are needed to advance the progress of nursing cost-effectiveness research.