Preventing recurrent homelessness among mentally ill men: a "critical time" intervention after discharge from a shelter

Benefits of the PRISM Shelter-Based Program for Attainment of Stable Housing and Functional Outcomes by People Experiencing Homelessness and Mental Illness: A Quantitative Analysis

OBJECTIVE

To explore the housing trajectory, personal recovery, functional level, and quality of life of clients at discharge and 1 year after completing Projet Réaffiliation Itinérance Santé Mentale (PRISM), a shelter-based mental health and rehabilitation program intended to provide individuals experiencing homelessness and severe mental illness with transition housing and to reconnect them with mental health and social services.

METHOD

Housing status, psychiatric follow-up trajectory, personal recovery (Canadian Personal Recovery Outcome Measure), functional level (Multnomah Community Ability Scale), and quality of life (Lehman Quality of Life Interview) were assessed at program entry, at program discharge and 1 year later.

RESULTS

Of the 50 clients who participated in the study from May 31, 2018, to December 31, 2019, 43 completed the program. Of these, 76.7% were discharged to housing modalities and 78% were engaged with psychiatric follow-up at the program's end. Housing stability, defined as residing at the same permanent address since discharge, was achieved for 62.5% of participants at 1-year follow-up. Functional level and quality of life scores improved significantly both at discharge and at 1-year follow-up from baseline.

CONCLUSIONS

Admission to PRISM helped clients secure long-term stable housing and appropriate psychiatric follow-up. Stable housing was maintained for most clients at 1-year follow-up, and they benefited from sustained functional and quality of life outcomes in long-term follow-up.

Case managers' reflections of a brief case management intervention in Canada

Introduction

As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM).

Objective

This study sought to explore case managers' perspectives and experiences with this new service delivery model.

Methods

Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis.

Results

Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention.

Conclusion

The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria.

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.

A Network Analysis of the Relationship Between Mental and Physical Health in Unsheltered Homeless Persons in Los Angeles County

Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.

Supporting Vulnerable People During Challenging Transitions: A Systematic Review of Critical Time Intervention

Critical Time Intervention (CTI) is designed to reduce the risk of homelessness and other adverse outcomes by providing support to individuals during challenging life course transitions. While several narrative reviews suggest the benefit of CTI, the evidence on the model's effectiveness has not been systematically reviewed. This article systematically reviews studies of CTI applied to a variety of populations and transition types. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis for protocols (PRISMA-P) guidelines, we reviewed 13 eligible experimental and quasi-experimental studies. Findings were summarized by individual outcome domains, including housing, service engagement use, hospitalization or emergency services, mental health, substance use, family and social support, and quality of life. CTI had a consistent positive impact on two primary outcomes-reduced homelessness and increased service engagement use-among different populations and contexts. Despite the effectiveness of CTI, the specific mechanisms of the model's positive impacts remain unclear. Implications for practice, policy and research are addressed.

Engaging stakeholders to inform national implementation of critical time intervention in a program serving homeless-experienced Veterans

The Veterans Affairs (VA) Grant and Per Diem Case Management "Aftercare" program provides 6 months of case management for homeless-experienced Veterans (HEVs) transitioning to permanent housing, with the aim of decreasing returns to homelessness. Implementing Critical Time Intervention (CTI)-an evidence-based case management practice-would standardize care across the 128 community-based agencies that provide Aftercare services. To prepare for national CTI implementation in Aftercare, guided by Replicating Effective Programs (REP), we conducted a four-site pilot in which we adapted a CTI implementation package (training, technical assistance, and external facilitation); characterized stakeholder perspectives regarding the acceptability and appropriateness of this package; and identified contextual factors that affected CTI implementation. We engaged a stakeholder workgroup to tailor existing CTI training and technical assistance materials for Aftercare. To provide tailored support for providers and leaders to adopt and incorporate evidence-based practices (EBPs) into routine care, we also developed external facilitation materials and processes. Over 9 months, we implemented this package at four sites. We conducted semi-structured interviews at pre-implementation, mid-implementation, and 6 months post-implementation, with HEVs (n = 37), case managers (n = 16), supervisors (n = 10), and VA leaders (n = 4); these data were integrated with templated reflection notes from the project facilitator. We used rapid qualitative analysis and targeted coding to assess the acceptability and appropriateness of CTI and our implementation package and identify factors influencing CTI implementation. Stakeholders generally found CTI acceptable and appropriate; there was consensus that components of CTI were useful and compatible for this setting. To adapt our implementation package for scale-up, this pilot highlighted the value of robust and tangible CTI training and technical assistance-grounded in real-world cases-that highlights the congruence of CTI with relevant performance metrics. Variations in agency-level contextual factors may necessitate more intense and tailored supports to implement and sustain complex EBPs like CTI. Processes used in this pilot are relevant for implementing other EBPs in organizations that serve vulnerable populations. EBP scale-up and sustainment can be enhanced by engaging stakeholders to tailor EBPs for specific contexts; pilot testing and refining implementation packages for scale-up; and using qualitative methods to characterize contextual factors that affect EBP implementation.

A Recovery-Oriented Intervention for People With Psychosis: A Pilot Randomized Controlled Trial

OBJECTIVE

This pilot randomized controlled trial evaluated the effectiveness of critical time intervention-task shifting (CTI-TS) for people with psychosis in Santiago, Chile, and Rio de Janeiro. CTI-TS is a 9-month intervention involving peer support workers and is designed to maintain treatment effects up to 18 months.

METHODS

A total of 110 people with psychosis were recruited when they enrolled in community mental health clinics (Santiago, N=60; Rio de Janeiro, N=50). Participants within each city were randomly assigned to either CTI-TS or usual care for 9 months. Primary outcomes were quality of life, measured with the World Health Organization Quality of Life Assessment-Brief Version (WHOQOL-BREF), and unmet needs, measured with the Camberwell Assessment of Need (CAN), at 18-month follow-up. Results were analyzed according to intention-to-treat guidelines. Generalized estimating equations, with observations clustered within cities, and multiple imputation for missing data were used.

RESULTS

At 18 months, both groups showed improved primary outcomes. In both unadjusted and fully adjusted analyses, no significant differences between CTI-TS and usual care (WHOQOL-BREF question on quality of life and CAN mean number of unmet needs) were found.

CONCLUSIONS

Three factors might explain the lack of difference between CTI-TS and usual care: first-contact enrollment precluded rapport prior to randomization, a minority of patients were uncomfortable with peers being on the treatment team, and primary outcome measures may not have been sensitive enough to capture the effects of a recovery-oriented intervention. The results have implications for the design of transitional services for people with psychosis, especially in Latin America.

Comparing two implementation strategies for implementing and sustaining a case management practice serving homeless-experienced veterans: a protocol for a type 3 hybrid cluster-randomized trial

Background

The Veterans Health Administration (VA) Grant and Per Diem case management “aftercare” program provides 6 months of case management for homeless-experienced veterans (HEVs) undergoing housing transitions. To standardize and improve aftercare services, we will implement critical time intervention (CTI), an evidence-based, structured, and time-limited case management practice. We will use two strategies to support the implementation and sustainment of CTI at 32 aftercare sites, conduct a mixed-methods evaluation of this implementation initiative, and generate a business case analysis and implementation playbook to support the continued spread and sustainment of CTI in aftercare.

Methods

We will use the Replicating Effective Programs (REP) implementation strategy to support CTI implementation at 32 sites selected by our partners. Half (n=16) of these sites will also receive 9 months of external facilitation (EF, enhanced REP). We will conduct a type 3 hybrid cluster-randomized trial to compare the impacts of REP versus enhanced REP. We will cluster potential sites into three implementation cohorts staggered in 9-month intervals. Within each cohort, we will use permuted block randomization to balance key site characteristics among sites receiving REP versus enhanced REP; sites will not be blinded to their assigned strategy. We will use mixed methods to assess the impacts of the implementation strategies. As fidelity to CTI influences its effectiveness, fidelity to CTI is our primary outcome, followed by sustainment, quality metrics, and costs. We hypothesize that enhanced REP will have higher costs than REP alone, but will result in stronger CTI fidelity, sustainment, and quality metrics, leading to a business case for enhanced REP. This work will lead to products that will support our partners in spreading and sustaining CTI in aftercare.

Discussion

Implementing CTI within aftercare holds the potential to enhance HEVs’ housing and health outcomes. Understanding effective strategies to support CTI implementation could assist with a larger CTI roll-out within aftercare and support the implementation of other case management practices within and outside VA.

Trial registration

This project was registered with ClinicalTrials.gov as “Implementing and sustaining Critical Time Intervention in case management programs for homeless-experienced Veterans.” Trial registration NCT05312229, registered April 4, 2022.

Treatment non-adherence pattern among persons with neuropsychiatric disorders: A study from a rural community mental health centre in India

BACKGROUND

Treatment gap causes significant loss to individuals, families, societies and the nation. Treatment adherence enhancement is a major challenge in psychiatric disorders. Globally, the community mental health services are obligated to minimize the treatment and adherence gap. In recent years' retrospective studies are gaining importance to measure the trend of mental health service utilization, cost effectiveness, resources allocation and similar aspects.

AIM

To explore the treatment adherence pattern of persons with neuropsychiatric illness from a rural community mental health centre.

METHOD

Five hundred and ninety-six medical records of persons with neuropsychiatric disorders who registered for outpatient treatment between 2015 and 2017 at Sakalawara Rural mental health centre of National Institute of Mental Health and Neuro Sciences, Bangalore, India, were reviewed to understand their adherence pattern.

RESULTS

Out of 596 patients, 68 (11.4%) were referred to tertiary care mental health and District Mental Health Programme (DMHP) services. Out of the remaining 528 patients, 29.7% were regular to mental health services over a period of 12 months and above; majority of the patients (36.2%) dropped out of their treatment after their first contact and 34.1% discontinued their follow up visits over a period of first week to 12 months.

CONCLUSION

Community based mental health centres too face challenges of and problems related to treatment non-adherence. Persons with neuropsychiatric disorders require continuity of care through regular home visits, out-reach services and innovative methods which will enhance treatment adherence.

Interventions to improve social circumstances of people with mental health conditions: a rapid evidence synthesis

BACKGROUND

Poor social circumstances can induce, exacerbate and prolong symptoms of mental health conditions, while having a mental health condition can also lead to worse social outcomes. Many people with mental health conditions prioritise improvement in social and functional outcomes over reduction in clinical symptoms. Interventions that improve social circumstances in this population should thus be considered a priority for research and policy.

METHODS

This rapid evidence synthesis reports on randomised controlled trials of interventions to improve social circumstances across eight social domains (Housing and homelessness; money and basic needs; work and education; social isolation and connectedness; family, intimate and caring relationships; victimisation and exploitation; offending; and rights, inclusion and citizenship) in people with mental health conditions. Economic evaluations were also identified. A comprehensive, stepped search approach of the Cochrane library, MEDLINE, Embase, PsycINFO, Web of Science and Scopus was conducted.

RESULTS

One systematic review and 102 randomised controlled trials were included. We did not find RCT evidence for interventions to improve family, intimate and caring relationships and only one or two trials for each of improving money and basic needs, victimisation and exploitation, and rights, inclusion and citizenship. Evidence from successful interventions in improving homelessness (Housing First) and employment (Individual Placement and Support) suggests that high-intensity interventions which focus on the desired social outcome and provide comprehensive multidisciplinary support could influence positive change in social circumstances of people with mental health conditions. Objective social isolation could be improved using a range of approaches such as supported socialisation and social skills training but interventions to reduce offending showed few benefits. Studies with cost and cost-effectiveness components were generally supportive of interventions to improve housing and vocational outcomes. More research is needed to ensure that social circumstances accompanied by high risks of further exacerbation of mental health conditions are adequately addressed.

CONCLUSIONS

Although there is a large body of literature examining how to support some aspects of life for people with mental health conditions, more high-quality evidence is required in other social domains. Integration into mental health services of interventions targeting social circumstances could significantly improve a number of social outcomes.

PRISM: A Shelter-Based Partnership for People Experiencing Homelessness and Severe Mental Illness

PRISM (Projet Réaffiliation Itinérance Santé Mentale [Homelessness Mental Health Reaffiliation Project]) is a clinical service developed through partnerships between shelters and the publicly funded Canadian health care system to address the needs of individuals experiencing homelessness and severe mental illness in Montreal. It provides inpatient treatment in a shelter setting for 2-3 months while helping clients find housing and appropriate longer-term support services. From program inception in November 2013 to May 2019, 52% of the 579 PRISM clients were in permanent housing after program discharge, 11% were in temporary housing, and 21% were not housed (homeless or incarcerated). In addition, 16% were transferred to inpatient treatment or rehabilitation services, and 85% were referred to and engaged in outpatient or community services.

Testing implementation facilitation for uptake of an evidence-based psychosocial intervention in VA homeless programs: A hybrid type III trial

Background

Healthcare systems face difficulty implementing evidence-based practices, particularly multicomponent interventions. Additional challenges occur in settings serving vulnerable populations such as homeless Veterans, given the population’s acuity, multiple service needs, and organizational barriers. Implementation Facilitation (IF) is a strategy to support the uptake of evidence-based practices. This study’s aim was to simultaneously examine IF on the uptake of Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking-Veterans Edition (MISSION-Vet), an evidence-based multicomponent treatment engagement intervention for homeless Veterans with co-occurring mental health and substance abuse, and clinical outcomes among Veterans receiving MISSION-Vet.

Methods

This multi-site hybrid III modified stepped-wedge trial involved seven programs at two Veterans Affairs Medical Centers comparing Implementation as Usual (IU; training and educational materials) to IF (IU + internal and external facilitation).

Results

A total of 110 facilitation events averaging 27 minutes were conducted, of which 85% were virtual. Staff (case managers and peer specialists; n = 108) were trained in MISSION-Vet and completed organizational readiness assessments (n = 77). Although both sites reported being willing to innovate and a desire to improve outcomes, implementation climate significantly differed. Following IU, no staff at either site conducted MISSION-Vet. Following IF, there was a significant MISSION-Vet implementation difference between sites (53% vs. 14%, p = .002). Among the 93 Veterans that received any MISSION-Vet services, they received an average of six sessions. Significant positive associations were found between number of MISSION-Vet sessions and outpatient treatment engagement measured by the number of outpatient visits attended.

Conclusions

While staff were interested in improving patient outcomes, MISSION-Vet was not implemented with IU. IF supported MISSION-Vet uptake and increased outpatient service utilization, but MISSION-Vet still proved difficult to implement particularly in the larger healthcare system. Future studies might tailor implementation strategies to organizational readiness.

Trial registration

ClinicalTrials.gov, NCT02942979.

Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study

Background

Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges.

Methods

We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed.

Results

From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges.

Conclusions

A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.

Frequent Episodic Utilizers of Veterans Health Administration Homeless Programs Use: Background Characteristics and Health Services Use

OBJECTIVE

To assess sociodemographic, diagnostic, and services use factors associated with veterans' repeated, episodic use of Veterans Health Administration (VHA) Homeless Programs.

DESIGN

This retrospective cohort study used stepwise multivariate logistic regression to assess the odds of veterans being frequent episodic utilizers of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period).

SETTING

The study used administrative data from veterans who accessed VHA services across the United States.

PARTICIPANTS

The sample comprised 31 098 veterans who completed a VHA Homeless Program intake assessment in 2013 and accessed VHA Homeless Programs during 2013-2016.

MAIN OUTCOME MEASURE

Frequent episodic use of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period).

RESULTS

Only 2.4% of the study sample had 4 or more episodes of VHA Homeless Program use during the observation period; risk factors included experience of military sexual trauma, history of incarceration, diagnosis of psychosis and substance use disorder, and use of acute care.

CONCLUSIONS

Addressing veterans' needs related to poverty, income, and postincarceration reintegration may reduce the frequent episodic use of VHA Homeless Programs. Interventions embedded in emergency departments and inpatient units may also be considered.

Understanding Users' Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in Chile

This study explores the beliefs and attitudes about the psychosocial mechanisms of peer support work among users who participated in Critical Time Intervention-Task Shifting (CTI-TS), which tested the acceptability and feasibility of a peer support work model to improve community-based mental health care for individuals with psychosis in Latin America. We conducted a secondary analysis of 15 in-depth interviews with CTI-TS participants in Chile, using the framework method and defined the framework domains based on five major mechanisms of peer support work identified by a recent literature review. The analysis revealed that users' perceptions of peer support work mechanisms were strongly shaped by personal motivations, beliefs about professional hierarchies, familial support, and the Chilean mental health system's incipient recovery orientation. The findings underscore the importance of adopting culturally tailored strategies to promote peer support work, such as involving mental health professionals and fostering equal-powered relationships between PSWs and users.

Supporting prisoners with mental health needs in the transition to RESETtle in the community: the RESET study

BACKGROUND

Homelessness is linked to poor mental health and an increased likelihood of offending. People often lose accommodation when they enter prison and struggle to find accommodation upon release leading to an increased likelihood of relapse and reoffending. The RESET intervention was developed to support prisoners with mental health needs for 12 weeks after release to coordinate their transition into the community and obtaining secure housing.

METHODS

The primary objective of the study was to assess the participants housing situation. A prospective cohort design followed up 62 prisoners with mental health needs for 9 months post-release. Data were collected at three time points regarding accommodation, reoffending and contact and engagement with services. Inferential statistics using Chi-squared tests and t tests were used to examine differences in scores between the two groups at each time point.

RESULTS

The RESET group was significantly more likely to have secure housing at all three time points being housed for approximately twice as many days than the comparison group (244 vs 129 days at 9 months: p ≤ 0.01). The RESET group also had a significantly greater level of contact with GPs and significantly more received benefits at all three time points.

CONCLUSION

This is the first study to focus on reducing homeless for recently released prisoners with mental health needs. The RESET intervention was successful in achieving its main objective; accommodating participants in permanent housing and reducing homelessness. There was also an association between receiving the intervention and greater engagement with other services. This supports the view that secure housing is important in ensuring a positive transition from prison to the community for prisoners with mental health needs.

The Psychometric Properties of the Assertive Community Treatment Transition Readiness Scale (ATR)

Assertive community treatment (ACT) is an evidence-based practice for individuals living with severe mental illnesses. Originally conceptualized as a lifetime service, there is a need for standardized measures to help ACT teams identify clients who are potentially ready for a transition to less intensive services. Here, to address this gap in the literature, the psychometric properties of the Assertive Community Treatment Transition Readiness Scale (ATR) were examined. Data on the ATR were collected from ACT staff from across the country who had experience transitioning ACT clients to less intensive services. Results from an exploratory factor analysis suggested a one-factor solution and that items on the ATR demonstrated excellent internal consistency reliability as well as predictive criterion validity and known-groups validity. The ATR is an easy-to-use, 18-item measure that has the potential, in combination with clinical judgment and practice wisdom, to be a useful tool for identifying ACT clients who could transition to a less intensive level of care.

Trauma-related differences in socio-emotional functioning predict housing and employment outcomes in homeless veterans

RATIONALE

Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability.

METHODS

The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects.

RESULTS

Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels.

CONCLUSION

Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment.

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.

Engaging vulnerable populations in drug treatment court: Six month outcomes from a co-occurring disorder wraparound intervention

OBJECTIVE

Although drug treatment courts (DTCs) have demonstrated positive outcomes, participants with co-occurring mental health and substance use disorders (CODs) are a high-risk group that often struggle with treatment engagement not previously examined. This pilot study fills this gap by looking at six-month behavioral health and criminal justice outcomes among a hard to engage DTC COD participant sample in two Massachusetts DTCs receiving a wraparound-treatment (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice - MISSION-CJ).

METHODS

Participants were evaluated at baseline and at six-month follow-up. Bivariate analyses examined baseline differences between clients with higher versus low engagement were examined. A mixed analysis of variance (ANOVA) for repeated measures with time as the within subject factor, and level of engagement as the between subject factor was performed for criminal justice (CJ) and behavioral health outcomes.

RESULTS

Participants were primarily male (86.6%), White (90.6%), living in unstable housing (86.2%), had an average of 18.94 years of criminal justice involvement, had an average of 15.49 years of regular illicit substance use, and mild mental health symptoms as measured by the BASIS-32 average total score (0.51), with no statistically significant differences at baseline from bivariate analyses. Mixed ANOVA results demonstrated significant effect time of time in MISSION-CJ on reducing nights in jail (p = 0.0266), opioid use (p = 0.0013), and mental health symptom (p = 0.0349). Additional improvements in nights in jail p = 0.0139), illicit substance use (p = 0.0358), and opioid use (p = 0.0013), were observed for clients that had high engagement in MISSION-CJ.

CONCLUSIONS

Wraparound services, such as MISSION-CJ, alongside DTC programming for a chronic relapsing DTC population can improve engagement in treatment and CJ and behavioral health outcomes. Future research is needed with MISSION-CJ that includes a randomized trial and a larger sample.

Pathways into and out of homelessness among people with severe mental illness in rural Ethiopia: a qualitative study

Background

Little is known about the pathways followed into and out of homelessness among people with experience of severe mental illness (SMI) living in rural, low-income country settings. Understanding these pathways is essential for the development of effective interventions to address homelessness and promote recovery. The aim of this study was to explore pathways into and out of homelessness in people with SMI in rural Ethiopia.

Methods

In-depth interviews were conducted with 15 people with SMI who had experienced homelessness and 11 caregivers. Study participants were identified through their participation in the PRIME project, which implemented a multi-component district level plan to improve access to mental health care in primary care in Sodo district, Ethiopia. People enrolled in PRIME who were diagnosed with SMI (schizophrenia, schizoaffective disorder or bipolar disorder) and who had reported experiencing homelessness at recruitment formed the sampling frame for this qualitative study. We used OpenCode 4.0 and Microsoft Excel for data management. Thematic analysis was conducted using an inductive approach.

Results

Study participants reported different patterns of homelessness, with some having experienced chronic and others an intermittent course. Periods of homelessness occurred when family resources were overwhelmed or not meeting the needs of the person with SMI. The most important pathways into homelessness were reported to result from family conflict and the worsening of mental ill health, interplaying with substance use in many cases. Participants also mentioned escape and/or wanting a change in environment, financial problems, and discrimination from the community as contributing to them leaving the home. Pathways out of homelessness included contact with (mental and physical) health care as a catalyst to the mobilization of other supports, family and community intervention, and self-initiated return.

Conclusions

Homelessness in people with SMI in this rural setting reflected complex health and social needs that were not matched by adequate care and support. Our study findings indicate that interventions to prevent and tackle homelessness in this and similar settings ought to focus on increasing family support, and ensuring access to acceptable and suitable housing, mental health care and social support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10629-8.

Implementation of a pilot community-based psychosocial intervention for patients with psychoses in Chile and Brazil: a comparative analysis of users' perspectives

BACKGROUND

Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations - incorporating a task-shifting approach and modifying the mode of community-based service delivery - are examined from users' perspectives.

METHODS

A secondary analysis of in-depth interviews with CTI-TS users (n = 9 in Brazil; n = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS.

RESULTS

Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil.

CONCLUSION

CTI-TS' major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.

Emergency medical services targeting opioid user disorder: An exploration of current out-of-hospital post-overdose interventions

OBJECTIVE

The opioid epidemic continues to escalate, and out-of-hospital emergency medical services (EMS) play a vital role in acute overdose reversal, but could serve a broader role post-incident for follow-up, outreach, and referrals. Our objective is to identify the scope and prevalence of community-based, post-opioid overdose EMS programs across the United States.

METHODS

We used a narrative review of prior studies in PubMed and Scopus for the last 20 years (1999-2020) to identify relevant medical literature and a web search to identify gray literature of EMS interventions involving opioids.

RESULTS

Out of nearly 22,000 EMS agencies across the United States, we found evidence of only 27 programs published in medical or gray literature involving post-overdose interventions. They were most commonly found in the north and eastern region of the country. Although most of these programs incorporate harm reduction and education, other more innovative aspects such as linkage to outpatient addiction treatment or peer support services, are much less common. The most comprehensive programs involved combinations of innovative outreach, specialized referrals, integration with police and criminal justice, peer support, and even treatment initiation.

CONCLUSIONS

Out-of-hospital emergency care has the potential to provide more comprehensive care after drug overdose, but many programs either do not currently have such an intervention in place, or are not disseminating their practices for other agencies to assimilate. EMS protocols and policies that encourage greater adoption of active community paramedicine practices for opioids should be encouraged.

A co-occurring disorders intervention for drug treatment court: 12-month pilot study outcomes

Purpose

Many individuals in drug treatment courts (DTCs) have co-occurring mental health and substance use disorders (COD), which can negatively impact treatment engagement, behavioral health and criminal justice outcomes. This paper aims to report results of DTC participants with a COD, who received a 12-month wraparound treatment intervention called MISSION-Criminal Justice (MISSION-CJ) alongside DTC to improve treatment engagement and behavioral health outcomes and reduce reincarcerations.

Design/methodology/approach

In this pre-post, single-group pilot, 48 clients enrolled and 81% completed 12-month follow-up assessments (N = 39) and weekly MISSION-CJ fidelity for type and intensity of services delivered. Generalized linear mixed models (GLMMs) were computed with a fixed term for fidelity (e.g. high or low MISSION-CJ), time and a fidelity x time interaction term.

Findings

Among participants, at 12 months, 81% of the participants remained engaged in treatment at study completion, and 89% had high MISSON-CJ fidelity. Clients demonstrated significant reductions from baseline to 12 months in average nights in jail (B = −0.1849511, p < 0.0344), mental health symptoms via the Behavior and Symptom Identification Scale (BASIS) total and subscale scores (B = −0.121613,p< 0.0186) and trauma symptoms on the PTSD Checklist-5 (PCL-5) (B = −0.928791, p < 0.0138). High MISSION-CJ fidelity further improved criminal justice, and behavioral health outcomes.

Originality/value

This was the first reported 12-month MISSION-CJ trial. While feasible to implement, given the design limitations, future research should include a large randomized controlled trial.

"En la Lucha": Strategies to Improve HIV Care for Puerto Ricans with Opioids Use Disorders

BACKGROUND

Clínica Bienestar is a comprehensive HIV primary care clinic for Spanish-speaking Latinx with opioids use disorders (OUD). This article describes the barriers and trajectories to HIV viral suppression for Puerto Ricans with a transnational profile and dual diagnoses (HIV and OUD), and the strategies applied to increase retention in care.

METHODS

Case study methodology was used to select two patient life histories that illustrate the most common pathways to success in reducing HIV viral load to undetectable and achieving OUD long-term recovery.

RESULTS AND DISCUSSION

Patients' major challenges included: (1) Persistent migrating while seeking substance use treatment services with limited or no support from their sending and hosting communities; (2) Intersectional stigmas; (3) Untreated trauma; (4) Language and cultural barriers. Clínica Bienestar's service model included ten strategies to retain patients in care (e.g., Case management to identify cases with high social isolation), six emerged as central to addressing transnational challenges.

Helping women transition out of sex work: study protocol of a mixed-methods process and outcome evaluation of a sex work exiting program

BACKGROUND

For women who want to, exiting sex work can be challenging. Numerous programs strive to help women wanting to exit sex work and secure alternative sources of income by providing targeted support at key moments during the transition, yet few of those initiatives are rigorously evaluated. In 2017 "Exit Doors Here", a 9-month sex work exiting program based on the critical time intervention (CTI) approach, was developed to provide wrap-around support services (e.g., health, addiction, housing, education, and employment supports) to women wishing to transition towards exiting sex work.

METHODS

We present the design of an evaluation study of Exit Doors Here which combines quantitative and qualitative methods to assess participant recruitment and retention into the program, program fidelity, and relationships with service providers (process evaluation), as well as progress made by participants in terms of strengthening their social support networks and moving closer to achieving their housing, pre-employment (i.e., educational, training and volunteering), and income-related goals, as well as their involvement in sex work (outcome evaluation). Each year for 4 years, between 25 and 30 Exit Doors Here clients will be invited to complete an interviewer-administered questionnaire at the beginning and after completing the program, and to share data from their CTI charts and related documentation. Once a year, program staff and peer workers will be interviewed, and service providers will be surveyed.

DISCUSSION

Conducting a formative (process) evaluation will allow us to inform program implementation and improve program delivery early on for maximum benefit. The summative (outcome) evaluation will provide much needed evidence on the effectiveness of CTI in supporting a traditionally underserved population to achieve the housing, pre-employment and income-related goals they value, and their progress towards reducing their involvement in, and eventually exiting, sex work.

Mental health services for single homeless people

Homelessness has long been associated with high rates of psychosis, alcohol and substance misuse, and personality disorder. However, psychiatric services in the UK have only recently engaged actively with homeless people. This article provides some background information about homelessness and mental illness and describes the elements of inclusion health and some of the models of service for homeless people that have been established over the past 30 years.

Substance use disorder patients’ expectations on transition from treatment to post-discharge period

Aim:

There is limited knowledge about how inpatients anticipate factors that facilitate the transition between specialised inpatient treatment for substance use disorder (SUD) and the post-discharge period. This study explores factors that inpatients anticipated would facilitate such a transition period.

Method:

A focus group study, consisting of four group interviews with individuals in inpatient SUD treatment, was conducted to explore their expectations for the transition and post-discharge period ahead of them. The transcribed interview material was analysed using thematic analysis.

Findings:

The analytical process led to three themes: “Belonging”, “Intrapersonal processes” and “Predictability”. Correspondence between inpatients’ expectations and the services they are offered in the transition and post-discharge period may serve as proper support for inpatients ahead of a vulnerable phase, such as the transition and post-discharge period.

Conclusions:

Findings from the current study highlight overarching elements that inpatients envisioned to be facilitating, such as social support, motivation, self-efficacy, self-awareness and predictability in basic elements such as employment, housing and personal finances. Findings from this study and previous ones imply that certain factors appear to facilitate in vulnerable phases, such as service level transitions. These facilitating factors should be taken into consideration and used as steppingstones through the transition and post-discharge period after inpatient SUD treatment.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

BACKGROUND

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations.

METHODS AND FINDINGS

We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management.

CONCLUSIONS

Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Pilot Study Evaluating Critical Time Intervention for Individuals With Hoarding Disorder at Risk for Eviction

Hoarding disorder has significant health consequences, including the devastating threat of eviction. In this pilot study, critical time intervention (CTI), an evidence-based model of case management shown to be effective for vulnerable populations, was adapted for individuals with severe symptoms of hoarding disorder at risk for eviction (CTI-HD). Of the 14 adults who enrolled, 11 participants completed the 9-month intervention. Completers reported a modest decrease in hoarding severity, suggesting that, while helpful, CTI-HD alone is unlikely to eliminate the risk of eviction for individuals with severe symptoms of hoarding disorder.

Implementing the protocol of a pilot randomized controlled trial for the recovery-oriented intervention to people with psychoses in two Latin American cities

Several Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America.

Homelessness in mental illness: Opportunities & prospects in the Indian context

Homelessness is considered a serious public health concern. Bidirectional relationship has been established between homelessness and mental illness by research studies and its association with compromised well-being, poor quality of life and low productivity. Recent legislative enactments in India have necessitated on the part of the state to address issues related to the rights of persons with mental illness including shelter and housing. Therefore, it becomes imperative to discuss opportunities and prospects in India towards rehabilitating homeless mentally ill in context of existing programs, policies and legislations.

NYC START: A New Model for Securing Community Services for Individuals Hospitalized for First-Episode Psychosis

OBJECTIVE

The New York City (NYC) Board of Health amended the city's health code to require hospitals to report to the Department of Health and Mental Hygiene when individuals ages 18-30 are hospitalized for first-episode psychosis (FEP). This study examined the implementation of NYC START, a program that meets patients hospitalized with FEP to offer a voluntary, 3-month critical time intervention provided by social workers and peer specialists to connect individuals to appropriate community mental health services after discharge.

METHODS

Service logs completed by program staff were summarized to determine the mean number of contacts received per client per week, types of services provided by social workers and peer specialists, survival analyses of time to discharge from NYC START, and connection rates with community mental health services.

RESULTS

Of the 285 clients who accepted NYC START services in 2016, 87% attended an initial mental health appointment after hospital discharge and 78% completed at least 3 months of the program. Consistent with the program model, contacts were most frequent in clients' first week in NYC START, with a mean of 2.5±1.4 contacts, 1.9 of which were with social workers and 0.5 of which were with peer specialists. Social workers provided a mean of 17.3±4.4 client-specific activities per week, and peer specialists provided a mean of 8.5±3.5.

CONCLUSIONS

NYC START serves as a critical time intervention to connect people hospitalized with FEP to community mental health treatment.

Evaluating the implementation of a prisoner re-entry initiative for individuals with opioid use and mental health disorders: Application of the consolidated framework for implementation research in a cross-system initiative

Given the interrelated nature of opioid use, criminal justice interaction, and mental health issues, the current opioid crisis has created an urgent need for treatment, including medication assisted treatment, among justice-involved populations. Implementation research plays an important role in improving systems of care and integration of evidence-based practices within and outside of criminal justice institutions. The current study is a formative qualitative evaluation of the implementation of a cross-system (corrections and community-based) opioid use treatment initiative supported by Opioid State Targeted Response (STR) funding. The purpose of the study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) to a cross-system initiative, and to identify key barriers and facilitators to implementation. The process evaluation showed that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent and structured forums for cross-system communication. Challenges related to recruitment and enrollment, staffing, MAT, and data collection were addressed through the collaborative development and continuous review of policies and procedures. This study found CFIR to be a useful framework for understanding implementation uptake and barriers. The framework was particularly valuable in reinforcing the use of implementation research as a means for continuous process improvement. CFIR is a comprehensive and flexible framework that may be adopted in future cross-system evaluations.

Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses

Homelessness represents an enduring public health threat facing communities across the developed world. Children, families, and marginalized adults face life course implications of housing insecurity, while communities struggle to address the extensive array of needs within heterogeneous homeless populations. Trends in homelessness remain stubbornly high despite policy initiatives to end homelessness. A complex systems perspective provides insights into the dynamics underlying coordinated responses to homelessness. A constant demand for housing assistance strains service delivery, while prevention efforts remain inconsistently implemented in most countries. Feedback processes challenge efficient service delivery. A system dynamics model tests assumptions of policy interventions for ending homelessness. Simulations suggest that prevention provides a leverage point within the system; small efficiencies in keeping people housed yield disproportionately large reductions in homelessness. A need exists for policies that ensure reliable delivery of coordinated prevention efforts. A complex systems approach identifies capacities and constraints for sustainably solving homelessness.

Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: a population-based cohort study

AIMS

A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care.

METHODS

This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 (N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge.

RESULTS

There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26-1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68-2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40-0.53)).

CONCLUSION

Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity.

How to help homeless youth suffering from first episode psychosis and substance use disorders? The creation of a new intensive outreach intervention team

In Canada, about 6,000 youth are homeless every night, many of whom suffer from addiction and psychotic disorders. To facilitate the exit out of homelessness, access to care and to improve psychosis and addiction outcomes, a new intensive outreach intervention team (EQIIP SOL) was created in Montreal (2012). It offers intensive outreach services dedicated to homeless youth suffering from first episode psychosis and addiction (HYFEPA) in addition to an early psychosis intervention service (EIS) in collaboration with the Addiction Psychiatry Unit. Our aim is to describe the characteristics, clinical, functional and housing outcomes of HYFEPA followed by EQIIP SOL. This two years long prospective longitudinal study with all HYFEPA (n = 42) admitted to EQIIP SOL between 2012-2015 reports at multiple time points, clinical (CGI, GAF), functional (SOFAS, work/study, housing autonomy) and substance use disorder (DUS, AUS) outcomes and acute services use (hospitalizations, emergency room visits). We observed that, at baseline, HYFEPA showed poor prognostic factors (eg. cluster B personality, substance use disorders, legal problems, childhood trauma and lower education level). The majority reached housing stability after 6 months and their functioning and illness severity improved with time. This suggests that HYFEPA improve with an intensive outreach intervention team integrated to an EIS.

Implementing a community-based task-shifting psychosocial intervention for individuals with psychosis in Chile: Perspectives from users

BACKGROUND

Latin America, and Chile in particular, has a rich tradition of community mental health services and programs. However, in vivo community-based psychosocial interventions, especially those with a recovery-oriented approach, remain scarce in the region. Between 2014 and 2015, a Critical Time Intervention-Task Shifting project (CTI-TS) was implemented in Santiago, Chile, as part of a larger pilot randomized control trial. CTI is a time-limited intervention delivered at a critical-time to users, is organized by phases, focuses on specific objectives and decreases in intensity over time. CTI-TS, which combines both the task-shifting strategy and the use of peers, introduces a novel approach to community mental health care that has not yet been tried in Chile.

AIMS

We aim to evaluate the feasibility, acceptability and applicability of such a community-based psychosocial intervention in urban settings in Latin America - specifically, in Santiago (Chile) from a user perspective.

METHOD

We analyzed 15 in-depth interviews ( n = 15) with service users who participated in the intervention about their perceptions and experiences with CTI-TS through thematic analysis.

RESULTS

Three themes were revealed. The first was related to the structural characteristics of CTI-TS, especially regarding the timing, duration and phasic nature of the intervention. The second pertained to the acceptability of the in vivo community-based approach. The third theme dealt with the task-shifting aspect, that is, users' perceptions of the peer support workers and the community mental health workers.

CONCLUSIONS

CTI-TS was generally acceptable in this Latin American context. Users' perspectives pointed to the need to make adjustments to some of the structural characteristics of the CTI model and to combine this type of intervention with others that can address stigma. Thus, future adaptations of CTI-TS or similar psychosocial interventions in Latin American contexts are feasible and can enhance community mental health in the region.

Bridging Hospital and Community Care for Homeless Adults with Mental Health Needs: Outcomes of a Brief Interdisciplinary Intervention

OBJECTIVE

This study examines health and service use outcomes and associated factors among homeless adults participating in a brief interdisciplinary intervention following discharge from hospital.

METHOD

Using a pre-post cohort design, 223 homeless adults with mental health needs were enrolled in the Coordinated Access to Care for the Homeless (CATCH) program, a 4- to 6-month interdisciplinary intervention offering case management, peer support, access to primary psychiatric care, and supplementary community services. Study participants were interviewed at program entry and at 3- and 6-month follow-up visits and assessed for health status, acute care service use, housing outcomes, mental health, substance use, quality of life, and their working alliance with service providers. Linear mixed models and generalized estimating equations were performed to examine outcomes longitudinally. Additional post hoc analyses evaluated differences between CATCH participants and a comparison group of homeless adults experiencing mental illness who received usual services over the same period.

RESULTS

In the pre-post analyses, CATCH participants had statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions. The strength of the working alliance between participants and their case manager was associated with reduced health care use and mental health symptoms. Post hoc analyses suggest that CATCH may be associated with statistically significant improvements in mental health symptoms in the study population.

CONCLUSIONS

A brief interdisciplinary intervention may be a promising approach to improving health outcomes among homeless adults with unmet health needs. Further rigorous research is needed into the effectiveness of brief interventions following discharge from hospital.

Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals

OBJECTIVE

Among individuals experiencing chronic homelessness, there is a high rate of co-occurring mental health and substance use, which has traditionally been addressed through the delivery of permanent supportive housing along with substance use and mental health services. However, this population often has difficulty engaging in treatment for co-occurring disorders, which can result in exacerbation of symptoms and housing loss. Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION) is a co-occurring mental health and substance use wraparound approach that was pilot-tested alongside Permanent Supportive Housing (PSH) to improve treatment access and engagement. This pilot was part of a state plan to end homelessness in the Boston metro area.

METHODS

This open pilot study enrolled 136 individuals who were chronically homeless and offered one year of MISSION along with PSH. Program participants also received baseline and 6- and 12-month follow-up assessments.

RESULTS

At one-year follow-up, 82.4% of the program participants were housed in PSH. However, due to limited affordable housing in the Boston metro area, it took on average 6.20 months to house the program participants. Furthermore, while MISSION was feasible to implement alongside PSH, fidelity to the MISSION model was lower than expected. This pilot also examined the role of housing status on clinical outcomes and found that the program participants who were housed at the time of discharge displayed a statistically significant improvement in emergency room visits for mental health complaints, the Psychosis subscale of the Behavior and Symptom Identification Scale (BASIS-32), illegal drug use, and pharmacotherapy treatment.

CONCLUSIONS

This pilot study demonstrated that systematically integrating PSH and MISSION can improve access and engagement in care, housing retention, and mental health outcomes. Despite the preliminary success and while taking into account the limitations of the open single-group pre/post design, this study also identified the lack of affordable housing as a potential barrier to placement as well as the critical role of housing for improved clinical outcomes. Randomized controlled trials are needed to test MISSION with PSH as well as perhaps PSH with and without MISSION to tease apart the effects of integrating both approaches simultaneously.

An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial

BACKGROUND

Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet.

METHODS

This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models.

RESULTS

Treatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received "higher" and "lower" intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use.

CONCLUSIONS

Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care.

TRIAL REGISTRATION

Clinicaltrials.gov, registration number: NCT01430741 , registered July 26, 2011.

Deinstitutionalization of long stay patients in a psychiatric hospital in Rio de Janeiro

Critical Time Intervention (CTI) is a time-limited mental health intervention offered to people with mental disorders during critical/transition periods. This study assesses the impact of CTI-BR on social performance and quality of life within a population in the process of deinstitutionalization, after long-term hospitalization in a psychiatric institution. The study population was split into two groups, one of which received CTI plus the regular care. Results showed no advantage of the intervention compared to the regular programs provided by the institution. When study participants are analyzed as a group, we found positive improvement regarding their social functioning and self-perception of their mental-health. Results show that it is possible for elderly patients discharged from long-term psychiatric care to live in residential facilities in the community, supervised by clinical teams.

Effectiveness of interventions to reduce homelessness: a systematic review and meta-analysis

This Campbell systematic review examines the effectiveness of interventions to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming homeless. Forty-three studies were included in the review, 37 of which are from the USA. Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are: High intensity case managementHousing FirstCritical time interventionAbstinence-contingent housingNon-abstinence-contingent housing with high intensity case managementHousing vouchersResidential treatment These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.

Plain Language Summary

Interventions to reduce homelessness and improve housing stability are effective: There are large numbers of homeless people around the world. Interventions to address homelessness seem to be effective, though better quality evidence is required.What is this review about?: There are large numbers of homeless people around the world. Recent estimates are over 500,000 people in the USA, 100,000 in Australia and 30,000 in Sweden. Efforts to combat homelessness have been made on national levels as well as at local government levels.This review assesses the effectiveness of interventions combining housing and case management as a means to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming homeless.What studies are included?: Included studies were randomized controlled trials of interventions for individuals who were already, or at-risk of becoming, homeless, and which measured impact on homelessness or housing stability with follow-up of at least one year.A total of 43 studies were included. The majority of the studies (37) were conducted in the United States, with three from the United Kingdom and one each from Australia, Canada, and Denmark.What are the main findings of this review?: Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are: High intensity case managementHousing FirstCritical time interventionAbstinence-contingent housingNon-abstinence-contingent housing with high intensity case managementHousing vouchersResidential treatment These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.What do the findings of this review mean?: A range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services.However, there is uncertainty in this finding as most the studies have risk of bias due to poor reporting, lack of blinding, or poor randomization or allocation concealment of participants. In addition to the general need for better conducted and reported studies, there are specific gaps in the research with respect to: 1) disadvantaged youth; 2) abstinence-contingent housing with case management or day treatment; 3) non-abstinence contingent housing comparing group vs independent living; 4) Housing First compared to interventions other than usual services, and; 5) studies outside of the USA.How up-to-date is this review?: The review authors searched for studies published up to January 2016. This Campbell systematic review was published in February 2018.

Executive summary

Background: The United Nations Universal Declaration of Human Rights (Article 25) states that everyone has a right to housing. However, this right is far from being realized for many people worldwide. According to the United Nations High Commissioner for Refugees (UNHCR), there are approximately 100 million homeless people worldwide. The aim of this report is to contribute evidence to inform future decision making and practice for preventing and reducing homelessness.Objectives: To identify, appraise and summarize the evidence on the effectiveness of housing programs and case management to improve housing stability and reduce homelessness among people who are homeless or at-risk of becoming homeless.Search methods: We conducted a systematic review in accordance with the Norwegian Knowledge Centre's handbook. We systematically searched for literature in relevant databases and conducted a grey literature search which was last updated in January 2016.Selection criteria: Randomized controlled trials that included individuals who were already, or at-risk of becoming, homeless were included if they examined the effectiveness of relevant interventions on homelessness or housing stability. There were no limitations regarding language, country or length of homelessness. Two reviewers screened 2,918 abstracts and titles for inclusion. They read potentially relevant references in full, and included relevant studies in the review.Data collection and analysis: We pooled the results and conducted meta-analyses when possible. Our certainty in the primary outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation for effectiveness approach (GRADE).Results: We included 43 relevant studies (described in 78 publications) that examined the effectiveness of housing programs and/or case management services on homelessness and/or housing stability. The results are summarized below. Briefly, we found that the included interventions performed better than the usual services in all comparisons. However, certainty in the findings varied from very low to moderate. Most of the studies were assessed as having high risk of bias due to poor reporting, lack of blinding, or poor randomization and/or allocation concealment of participants.Case management: Case management is a process where clients are assigned case managers who assess, plan and facilitate access to health and social services necessary for the client's recovery. The intensity of these services can vary. One specific model is Critical time intervention, which is based on the same principles, but offered in three three-month periods that decrease in intensity.High intensity case management compared to usual services has generally more positive effects: It probably reduces the number of individuals who are homeless after 12-18 months by almost half (RR=0.59, 95%CI=0.41 to 0.87)(moderate certainty evidence); It may increase the number of people living in stable housing after 12-18 months and reduce the number of days an individual spends homeless (low certainty evidence), however; it may have no effect on the number of individuals who experience some homelessness during a two year period (low certainty evidence). When compared to low intensity case management, it may have little or no effect on time spent in stable housing (low certainty evidence).Critical time intervention compared to usual services may 1) have no effect on the number of people who experience homelessness, 2) lead to fewer days spent homeless, 3) lead to more days spent not homeless and, 4) reduce the amount of time it takes to move from shelter to independent housing (low certainty evidence).Abstinence-contingent housing programs: Abstinence-contingent housing is housing provided with the expectation that residents will remain sober. The results showed that abstinence-contingent housing may lead to fewer days spent homeless, compared with usual services (low certainty evidence).Non-abstinence-contingent housing programs: Non-abstinence-contingent housing is housing provided with no expectations regarding sobriety of residents. Housing First is the name of one specific non-abstinence-contingent housing program. When compared to usual services Housing First probably reduces the number of days spent homeless (MD=-62.5, 95%CI=-86.86 to -38.14) and increases the number of days in stable housing (MD=110.1, 95%CI=93.05 to 127.15) (moderate certainty evidence). In addition, it may increase the number of people placed in permanent housing after 20 months (low certainty evidence).Non-abstinence-contingent housing programs (not specified as Housing First) in combination with high intensity case management may reduce homelessness, compared to usual services (low certainty evidence). Group living arrangements may be better than individual apartments at reducing homelessness (low certainty evidence).Housing vouchers with case management: Housing vouchers is a housing allowance given to certain groups of people who qualify. The results showed that it mayreduce homelessness and improve housing stability, compared with usual services or case management (low certainty evidence).Residential treatment with case management: Residential treatment is a type of housing offered to clients who also need treatment for mental illness or substance abuse. We found that it mayreduce homelessness and improve housing stability, compared with usual services (low certainty evidence).Authors' conclusions: We found that a range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services. The findings showed no indication of housing programs or case management resulting in poorer outcomes for homeless or at-risk individuals than usual services.Aside from a general need for better conducted and reported studies, there are specific gaps in the research. We identified research gaps concerning: 1)Disadvantaged youth; 2) Abstinence-contingent housing with case management or day treatment; 3) Non-abstinence contingent housing, specifically different living arrangements (group vs independent living); 4) Housing First compared to interventions other than usual services, and; 5) All interventions from contexts other than the USA.

Critical Time Intervention for People Leaving Shelters in the Netherlands: Assessing Fidelity and Exploring Facilitators and Barriers

International dissemination of evidence-based interventions calls for rigorous evaluation. As part of an evaluation of critical time intervention (CTI) for homeless people and abused women leaving Dutch shelters, this study assessed fidelity in two service delivery systems and explored factors influencing model adherence. Data collection entailed chart review (n = 70) and two focus groups with CTI workers (n = 11). The intervention obtained an overall score of three out of five (fairly implemented) for compliance fidelity and chart quality combined. Fidelity did not differ significantly between service systems, supporting its suitability for a range of populations. The eight themes that emerged from the focus groups as affecting model adherence provide guidance for future implementation efforts.

The effectiveness of critical time intervention for abused women leaving women's shelters: a randomized controlled trial

Objectives

To examine the effectiveness of critical time intervention (CTI)—an evidence-based intervention—for abused women transitioning from women’s shelters to community living.

Methods

A randomized controlled trial was conducted in nine women’s shelters across the Netherlands. 136 women were assigned to CTI (n = 70) or care-as-usual (n = 66). Data were analyzed using intention-to-treat three-level mixed-effects models.

Results

Women in the CTI group had significant fewer symptoms of post-traumatic stress (secondary outcome) (adjusted mean difference − 7.27, 95% CI − 14.31 to − 0.22) and a significant fourfold reduction in unmet care needs (intermediate outcome) (95% CI 0.06–0.94) compared to women in the care-as-usual group. No differences were found for quality of life (primary outcome), re-abuse, symptoms of depression, psychological distress, self-esteem (secondary outcomes), family support, and social support (intermediate outcomes).

Conclusions

This study shows that CTI is effective in a population of abused women in terms of a reduction of post-traumatic stress symptoms and unmet care needs. Because follow-up ended after the prescribed intervention period, further research is needed to determine the full long-term effects of CTI in this population.

Electronic supplementary material

The online version of this article (10.1007/s00038-017-1067-1) contains supplementary material, which is available to authorized users.