The effect of a Housing First intervention on primary care retention among homeless individuals with mental illness

FAIRSTEPS study - Framework Addressing Inequities in pRimary care using STakEholder PerspectiveS: Integrative evidence review and Delphi consensus

OBJECTIVES

Health inequities are unjust and avoidable differences in health outcomes across populations and between population groups. Though these arise predominantly from social determinants of health, healthcare is estimated to contribute around 20 % and primary healthcare reduces inequities in healthcare outcomes. As each provider works in their local context, we sought to provide an evidence-informed framework for designing, implementing, and evaluating local health inequity interventions in primary care.

STUDY DESIGN

Mixed methods approach: an integrative evidence review, a multidisciplinary Delphi consensus study and collaborative patient and public participation.

METHODS

We searched published and grey literature for examples of primary care health inequity interventions. Our Delphi survey then asked primary care professionals how feasible and useful similar interventions would be in their local contexts. We incorporated an ongoing dialogue people with lived experience of health inequity in our design, implementation, and analysis.

RESULTS

Sixty-nine published papers and 19 grey literature papers were included. Interventions included multiple objectives (e.g., tailored provision, practitioner training) or focus (e.g., medical care, screening). Theory underpinning intervention design was rarely explicit but some specific tools and theory was identified for the framework. Practitioners and our patient group prioritised 28 example interventions to aid the design of local contextually sensitive interventions.

CONCLUSIONS

We combined evidence synthesis, practitioner consultation and dialogue with people with lived experience produced an evidence-informed framework for the design, implementation and evaluation of local primary care health inequity interventions. The public and practitioner voice increases the credibility of our framework as a useful tool for service development.

Changes in healthcare costs and utilization for Medicaid recipients who received supportive housing through a payer-community-based housing partnership

OBJECTIVE

To evaluate healthcare cost and utilization changes among Medicaid and dually eligible participants of a supportive housing program implemented by a managed care organization and community-based organization.

STUDY SETTING AND DESIGN

Healthcare claims were reviewed retrospectively for 80 program participants in one urban Pennsylvania county between 1/1/2018 and 9/28/2023 who had ≥6 months of claims data in both pre- and post-housing periods. Eligibility included age >18 years, Medicaid/Special Needs Plan enrollment, and housing need. Due to limited housing units, potential participants were prioritized by medical need and history of unplanned care.

DATA SOURCES AND ANALYTIC SAMPLE

Healthcare cost and utilization were compared during pre- (i.e., 12 months before housing initiation) and post-periods (i.e., 12 months after housing initiation).

PRINCIPAL FINDINGS

Compared to the pre-period, significantly lower medical (-40.4%, p = 0.004), emergency department (-62.7%, p = 0.02), and total (-33.3%, p = 0.02) costs of care were observed in the post-period. Significantly lower primary care (-50.0%, p = 0.0003), specialist (-31.3%, p = 0.02), and emergency department (-50.0%, p = 0.03) utilization were also observed.

CONCLUSIONS

Healthcare cost and utilization among medically complex individuals were lower with supportive housing. Future evaluations with randomized designs can address the potential causal impact of supportive housing as a healthcare intervention on specific outcomes.

Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

BACKGROUND

Homelessness creates a significant social and economic burden in the society. Homelessness and mental illness are two interconnected social issues that poses challenges to individuals and communities across the globe. This systematic review aims to synthesize the existing literature on interventions for the homeless persons with mental illness.

OBJECTIVES

To systematically review the existing literature on psychosocial interventions for homeless persons with mental illness.

SEARCH METHODS

Five databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar were searched using homelessness, psychosocial interventions, mental ill, residential mental health facility, and case management for experimental studies published from January 2000 to December 2022.

STUDY SELECTION

Abstract review was conducted for the screened studies, and full-text review was done for studies which met inclusion exclusion criteria.

DATA EXTRACTION AND ANALYSIS

Among the 6,387 studies screened 20 studies were selected which fulfilled inclusion criteria. The full text review yielded data of 12,174 homeless persons with mental illness who undergone intervention.

RESULTS

The major psychosocial interventions found including critical time intervention, case management, housing support intervention, assertive community treatment, and life skills training. These interventions were helpful in sustaining housing stability, preventing relapse, reducing hospitalizations, and improving quality of life of the homeless persons with mental illness.

CONCLUSION

Targeted and integrated interventions addressing homelessness and mental illness are required to tackle the social problems of homelessness and mental illness. Further research is required to explore the most effective strategies that address homelessness and mental illness.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

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.