Longitudinal Impact of a Family Critical Time Intervention on Children in High-Risk Families Experiencing Homelessness: A Randomized Trial

Significance of fostering the mental health of patients with diabetes through critical time intervention

BACKGROUND

Critical time intervention (CTI) is an evidence-based model of practice that is time-limited and aims to provide support for most susceptible individuals during a transition period.

AIM

To examine the significance of fostering the mental health of diabetes patients through CTI using the scoping review methodology.

METHODS

As part of the scoping review process, we followed the guidelines established by the Joanna Briggs Institute. The search databases were Google Scholar, PubMed, Scopus, PsycINFO, Reference Citation Analysis (https://www.referencecitationanalysis.com/), and Cochrane Library. From these databases, 77 articles were retrieved with the aid of carefully selected search terms. However, 19 studies were selected after two reviewers appraised the full texts to ensure that they are all eligible for inclusion, while 54 papers were excluded.

RESULTS

This study revealed that diabetic patients who had experienced homelessness were at higher risk of being diagnosed with mental illness and that social support services are impactful in the management of the comorbidity of diabetes and mental health problems. In addition, this review reveals that CTI is impactful in enhancing the mental health of homeless patients during the transitional period from the hospital through social support services.

CONCLUSION

CTI is a promising intervention for alleviating mental health symptoms in homeless patients. Empirical studies are needed across the globe, involving both hospitalized and community-based patients, to determine how clinically effectively CTI is in managing the mental health of diabetics.

Effect of a Social Care Intervention on Health Care Experiences of Caregivers of Hospitalized Children: A Randomized Clinical Trial

Importance

Health-related social risks (HRSRs), like food and housing insecurity, are stigmatized conditions that, when addressed in clinical settings, could inadvertently compromise health care experiences.

Objective

To test the noninferiority hypothesis that a low-intensity, high-scale social care intervention does not promote experiences of discrimination or diminish satisfaction with care compared to usual care.

Design, Setting, and Participants

This was a double-blind randomized clinical trial conducted from November 2020 to June 2022 with 12-month follow-up analyzing data obtained 1 week after baseline intervention at a 155-bed academic urban children's hospital with 5300 annual admissions. Participants were recruited from their children's hospital rooms during their children's inpatient hospital stays. Inclusion criteria were identifying as the primary caregiver of a child younger than 18 years who was hospitalized in the general, intensive care, or transplant units; living in 1 of 42 target zip codes; and consenting to receive text messages. Caregivers of healthy newborns and caregivers of children expected to be hospitalized for less than 24 hours or greater than 30 days were excluded. A total of 637 eligible parents and caregivers were enrolled.

Interventions

Participants were randomized to usual care or usual care plus CommunityRx, a low-intensity, universally delivered, electronic medical record-integrated social care assistance intervention providing personalized information about local resources alongside education about HRSRs and how to access additional support. Usual care included an admission brochure about hospital-based free food options and nonsystematic provision of resource information.

Main Outcomes and Measures

Experiences of discrimination, measured using the Discrimination in Medical Settings Scale (range 7-35; higher scores indicate more frequent discrimination) and satisfaction with hospital discharge 1 week postdischarge using Child HCAHPS (range 0-100; higher scores indicate higher satisfaction). The a priori noninferiority margins (control minus intervention) were -0.9 (discrimination) and 1.6 (satisfaction).

Results

Of 637 eligible caregiver participants, most identified as female (n = 600 [94.3%]), Black (n = 505 [79.4%]), and had household income less than $50 000 per year (n = 488 [78.5%]). One-third were experiencing food insecurity (n = 223). Half of participants reported discrimination experiences during the pediatric hospitalization (n = 259). Discrimination experiences among the intervention group were noninferior to those among the control group (mean [SD] score: control, 10.3 [4.7] vs intervention, 10.0 [4.6]; difference, 0.2; 90% CI, -0.5 to 0.9). Mean (SD) satisfaction with discharge was high (control, 84.2 [23.8] vs intervention, 81.9 [24.8]), but evidence was insufficient to support intervention noninferiority for this end point (difference, 2.3; 90% CI, -1.2 to 5.8). Food security status did not moderate the relationship between intervention and either outcome.

Conclusions and Relevance

The findings suggest that a universally delivered social care assistance intervention did not promote caregiver experiences of discrimination during a child's hospitalization but were inconclusive regarding satisfaction.

Trial Registration

ClinicalTrials.gov Identifier: NCT04171999.

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.

Mothers' perceptions of how homelessness and housing interventions affect their children's behavioral and educational functioning

Children who experience homelessness display substantial variation in outcomes, but little attention has been given to potential mechanisms linking their housing experiences to their functioning. This study explores these mechanisms using qualitative coding of 80 interviews with parents participating in a randomized control trial of housing interventions for families experiencing homelessness. Interviews were conducted an average of 7 months after families entered a homeless shelter, when most families had exited shelters to a variety of other housing options. Many parents described children as faring poorly on behavioral and educational outcomes while in shelters but displaying improvement after leaving the shelter. Parents commonly viewed shelters as contributing to behavioral disruptions, with restored autonomy and routines after exiting shelters contributing to recovery in functioning. Parents offered long-term rental subsidies viewed having a stable, adequate place of their own as helping their children fare better from reduced family stress, improved routines, and changes in children's expectations about stability. Findings indicate the importance of understanding differences in housing stability and quality among families who experience homelessness for how children fare-including differences in how housing interventions affect stability and quality. Policies expanding access to long-term rental subsidies could help improve outcomes for children. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review

IMPORTANCE

Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities.

OBJECTIVE

To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity.

EVIDENCE REVIEW

Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity).

FINDINGS

Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences.

CONCLUSIONS AND RELEVANCE

In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.

Housing and supportive services for substance use and self-efficacy among young mothers experiencing homelessness: A randomized controlled trial

AIMS

Homeless mothers with young children in their care contend with high rates of substance use and low self-efficacy. However, a limited number of studies have examined these outcomes associated with housing and supportive services.

DESIGN

Participants were randomly assigned to: (1) housing + support services (n = 80), (2) housing-only (n = 80), or (3) services as usual (SAU) (n = 80) and were re-assessed at 3-, 6-, 9- and 12-months postbaseline.

SETTINGS

The study recruited a community-based sample from homeless service agencies and advertisements in a large Midwestern city.

PARTICIPANTS

The study recruited two hundred forty (N = 240) women between the ages of 18 to 24 years, experiencing homelessness and with a substance use disorder (SUD) who also had a biological child under the age of 6 years in their care.

MEASUREMENTS

We measured frequency of alcohol and drug use using the Form 90 semi-structured interview, and self-efficacy using Pearlin and Schooler's (1978) 7-item Mastery Scale.

FINDINGS

Overall, mothers showed significant improvement in substance use and self-efficacy over time in each condition. However, as expected, patterns of change differentiated intervention groups with more mothers showing better substance use and self-efficacy outcomes in housing + supportive services than in SAU. Unexpectedly, more mothers in SAU showed better outcomes than those in housing-only.

CONCLUSIONS

Substance use decreased and self-efficacy increased over time, but patterns of change characterized the intervention groups. In particular, findings suggest that when providing housing to this population, supportive services should also be offered.

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.

Leveraging research to inform prevention and intervention efforts: Identifying risk and protective factors for rural and urban homeless families within transitional housing programs

This mixed method study spotlights hardships and supportive factors for unhoused families led by single mothers who have successfully graduated from two transitional housing programs, one rural and one urban. Data collection consisted of entry and exit surveys (n = 241) as well as qualitative interviews (n = 11). Binary logistic regression results indicated education and social support as significant predictors of successful program completion. Qualitative findings further illustrate narratives surrounding supportive factors and program supports (i.e., assistance securing employment, education courses, sense of community), as well as policy implications. Implications stress the need for enhancing supportive factors (i.e., education and social capital) in early prevention efforts (e.g., schools and community centers), as well as an intentional integration of addressing socio-emotional needs and resources within housing programs and services unique to rural and urban communities.

Turning Off the Tap: A Typology for Homelessness Prevention

As states move beyond simply managing their homelessness crises to looking for ways to reduce and ultimately end homelessness, broad-scale efforts to prevent homelessness are lacking. Experiences of homelessness are often harmful, traumatic, and costly, making a compelling case for why homelessness prevention should be prioritized. In recent years, countries such as Australia, Finland, and Wales have shifted their focus to prevention, but there remains a conceptual and systematic gap in our collective knowledge about what precisely homelessness prevention is, what policies, programs, and interventions are captured in a homelessness prevention strategy, and how to build a framework for orienting our response to homelessness towards prevention. This article begins to fill that gap by providing a definition and typology of homelessness prevention (THP). Our definition offers a schema to clarify the nature of homelessness prevention and to develop a collective response between various policies and practices that can and should be framed as homelessness prevention. Building off of the public health model of prevention and pre-existing homelessness prevention classification systems, our THP complements the definition by specifying the pragmatic nature of prevention initiatives and the range of sectors, stakeholders, and levels of government required to respond to the causes of homelessness. Our typology is made up of five interrelated elements: structural, systems, early intervention, evictions prevention, and housing stabilization. Each of these elements contains actionable strategies that cut across primary, secondary, and tertiary prevention to ensure that people at various levels of risk have access to the tools and resources necessary to find and maintain safe, appropriate, and suitable housing. Together the definition and THP are useful tools to envision a new way forward in how we respond to homelessness.

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.

Family-based Intervention for Legal System-involved Girls: A Mixed Methods Evaluation

The increased proportion of juvenile court-involved girls has spurred interest to implement and evaluate services to reduce girls' system involvement. The purpose of this study was to examine the effectiveness of a family-based intervention by using a dominant sequential mixed methods evaluation approach. First, we examined quantitative data using a quasi-experimental design to determine whether the family-based intervention reduced recidivism among court-involved girls. Propensity score matching (PSM) was used to construct statistically equivalent groups to compare one-year recidivism outcomes for girls who received the court-run family-based intervention (n = 181) to a group of girls on probation who did not receive the intervention (n = 803). Qualitative interviews (n = 39) were conducted to contextualize the quantitative findings and highlighted the circumstances that family-focused interventions for court-involved girls. Girls who received the program had slightly lower recidivism rates following the intervention. The qualitative findings contextualized the quasi-experimental results by providing an explanation as to the girls' family circumstances and insights into the mechanisms of the intervention. Results highlighted the importance of family-focused interventions for juvenile justice-involved girls. These findings have practical and policy implications for the use interventions-beyond the individual level-with adjudicated girls and offer suggestions for ways to improve their effectiveness using a community psychology lens. In addition, this paper includes a discussion of evaluating of juvenile court programming from a community psychology perspective including strengths, challenges, and considerations for future work in this area.

Trauma and healing in the underserved populations of homelessness and corrections: Forgiveness Therapy as an added component to intervention

The purpose of this article is to begin applying the principles of the psychology of forgiveness to people who are without homes and people who are in prisons. A review of the literature shows trauma for both groups. When the trauma is caused by unjust treatment by others, then excessive anger can result, compromising one's psychological and physical health. We review the interventions that have been offered for those without homes and the imprisoned to examine which existing programmes address such anger. Forgiveness Therapy, although untried in these two settings, may be one beneficial approach for substantially reducing unhealthy anger. Forgiveness interventions have shown a cause-and-effect relationship between learning to forgive and overcoming psychological compromise such as strong resentment and clinical levels of anxiety and depression. The literature review here suggests that forgiveness therapy for those without homes and the imprisoned may be a new and important consideration for ameliorating anger and aiding in a changed life pattern.

Fidelity Assessment of a Social Work-Led Intervention Among Patients with Firearm Injuries

PURPOSE

To support future development and refinement of social work-led intervention programs among patients with firearm injuries and to demonstrate how a fidelity assessment can be used to adjust and refine intervention delivery in an ongoing trial.

METHODS

We conducted a fidelity assessment of a randomized controlled trial of a social work-led intervention among patients with a firearm injury.

RESULTS

We found that our study intervention was well implemented, meeting 70% of the fidelity assessment score items, however noted lower fidelity with client-based items.

DISCUSSION

As a result of fidelity assessment findings, we refined intervention delivery to improve implementation fidelity including beginning to review cases of all patients each month, rather than focusing on patients in crisis. Our fidelity assessment process and findings offer insight into the challenges of implementing an intervention among patients with firearm injuries and highlights the value of monitoring intervention fidelity during an ongoing trial.

Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review

CONTEXT

Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration.

OBJECTIVES

A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness.

DESIGN

A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate.

ELIGIBILITY CRITERIA

Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports.

MAIN OUTCOME MEASURES

Housing stability, physical and mental health outcomes, and health care utilization.

RESULTS

Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%.

CONCLUSIONS

Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

The psychological impact of childhood homelessness-a literature review

In August 2019, 3848 children in Ireland were faced with emergency homelessness [1]. In recent years, lack of affordable housing, unemployment and shortage of rental properties have been the primary driving factors for the potentially devastating impact of familial homelessness in our society [1]. Our aim was to evaluate current knowledge on the psychological impact of homelessness in children. Using the PRISMA model, we performed a review of the currently available literature on the psychological impact of homelessness on children. This concept was explored under two different categories-'transgenerational' and 'new-onset homelessness'. Hidden homelessness was also explored. Our literature review revealed several psychological morbidities which were unique to children. This includes developmental and learning delays, behavioural difficulties and increased levels of anxiety and depression [66, 77, 40, 81, 42]. This has been demonstrated by poorer performance in school testing and increased levels of aggression. Anxiety in children within this cohort has been shown to peak at time of dispersion from their stable home environment [67]. Our study highlights violence, aggression and poor academic learning outcomes to be just some of the key findings in our review of homelessness in childhood, worldwide. Unfortunately, there has been minimum research to date on paediatric homelessness within the context of the Irish population. We anticipate this review to be the first chapter in a multipart series investigation to evaluate the psychological morbidity of paediatric homelessness within the Irish Society.

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.

Resetting Policies to End Family Homelessness

Homelessness is a devastating experience for children and their families. Families, the majority of whose members are children, now comprise more than one-third of the overall US homeless population. Most of these children are less than six years old. Various assumptions have driven policy and the allocation of resources to programs serving these families. Although decades of research and field experience suggest strategies for preventing and reducing this problem, perspectives differ, hindering the development of effective solutions. In this article, we explore some of these assumptions, including (a) definitions of homelessness used to count the numbers of families and determine resource allocation, (b) the needs of children and responses to the impact of adverse childhood experiences, and (c) whether services matter and should be integrated with affordable housing. We conclude by suggesting various directions to ensure that these children are protected and have the opportunity to grow and thrive.

Scaling Up Housing Services Within the Child Welfare System: Policy Insights From Simulation Modeling

OBJECTIVES

Housing insecurity and homelessness contribute to risk of maltreatment among one in five of the nearly 3.5 million children annually investigated for maltreatment in the United States. The Family Unification Program (FUP)-a federal initiative-connects inadequately housed families involved in child welfare with long-term rental subsidies to avoid foster placement. However, FUP remains understudied and underutilized with funding levels that serve only a fraction of eligible households. The present study uses system dynamics modeling to inform decision-making by testing policies for scaling FUP.

METHOD

Simulations model delivery of FUP within child welfare from a feedback perspective. Calibrated on national data, models replicate trends in child welfare involvement from 2013 through 2016, and analyses forecast rates through 2019. Experiments test policies that enhance FUP. Outcomes track system-wide rates of family separation and returns on investment of expanded housing interventions.

RESULTS

Dramatic expansions of FUP benefit more families and improve marginal return on investment. Yet, scale-up fails to reduce system-wide rates of family separation or generates substantial cost-savings.

CONCLUSIONS

Simulations demonstrate structural challenges for scaling FUP. Constant demand for affordable housing constrains sustainable improvements in child protection. Child welfare responses to homelessness require innovations that reduce demand for housing services through prevention and earlier intervention.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) - a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs. The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.

Health Care Utilization and Expenditures of Homeless Family Members Before and After Emergency Housing

OBJECTIVES

To describe longitudinal health service utilization and expenditures for homeless family members before and after entering an emergency shelter.

METHODS

We linked Massachusetts emergency housing assistance data with Medicaid claims between July 2008 and June 2015, constructing episodes of health care 12 months before and 12 months after families entered a shelter. We modeled emergency department visits, hospital admissions, and expenditures over the 24-month period separately for children and adults.

RESULTS

Emergency department visits, hospital admissions, and expenditures rose steadily before shelter entry and declined gradually afterward, ending, in most cases, near the starting point. Infants, pregnant women, and individuals with depression, anxiety, or substance use disorder had significantly higher rates of all outcomes. Many children's emergency department visits were potentially preventable.

CONCLUSIONS

Increased service utilization and expenditures begin months before families become homeless and are potentially preventable with early intervention. Infants are at greater risk. Public Health Implications. Early identification and intervention to prevent homeless episodes, focusing on family members with behavioral health disorders, who are pregnant, or who have young children, may save money and improve family health.

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.

What Interventions Work Best for Families Who Experience Homelessness? Impact Estimates from the Family Options Study

What housing and service interventions work best to reduce homelessness for families in the United States? The Family Options Study randomly assigned 2,282 families recruited in homeless shelters across 12 sites to priority access to one of three active interventions or to usual care in their communities. The interventions were long-term rent subsidies, short-term rent subsidies, and transitional housing in supervised programs with intensive psychosocial services. In two waves of follow-up data collected 20and 37 months later, priority access to long-term rent subsidies reduced homelessness sand food insecurity and improved other aspects of adult and child well-being relative to usual care, at a cost 9 percent higher. The other interventions had little effect. The study provides support for the view that homelessness for most families is an economic problem that long-term rent subsidies resolve and does not support the view that families must address psychosocial problems to succeed in housing. It has implications for focusing government resources on this important social problem.

Permanent Housing for Child Welfare-Involved Families: Impact on Child Maltreatment Overview

A longitudinal randomized controlled trial tested whether access to permanent housing reduces child maltreatment among inadequately housed families under investigation for child abuse and neglect. The study followed homeless and child welfare-involved families randomly assigned to receive a referral for housing subsidies plus housing case management (n = 75, 196 children) or housing case management alone (n = 75, 186 children). Latent growth models examined change in caregiver-reported frequencies of psychological aggression, physical abuse, and neglect toward children at five time points across 2.5 years. Intent-to-treat analyses suggested treatment differences for minor assault and neglect that approached significance; families randomly assigned to permanent housing plus case management exhibited marginally greater declines compared to families referred for housing case management only. Caregiver psychological aggression remained high over time, regardless of treatment condition. No evidence indicated higher risk families benefitted more from permanent housing. Results show some promise of permanent housing and highlight the complex needs of homeless families under investigation for child maltreatment. Findings emphasize the importance of continued involvement from the child welfare system to connect families with important resources.

Can Housing and Service Interventions Reduce Family Separations for Families Who Experience Homelessness?

Family break-up is common in families experiencing homelessness. This paper examines the extent of separations of children from parents and of partners from each other and whether housing and service interventions reduced separations and their precursors among 1,857 families across 12 sites who participated in the Family Options Study. Families in shelters were randomized to offers of one of three interventions: permanent housing subsidies that reduce expenditures for rent to 30% of families' income, temporary rapid re-housing subsidies with some services directed at housing and employment, and transitional housing in supervised facilities with extensive psychosocial services. Each group was compared to usual care families who were eligible for that intervention but received no special offer. Twenty months later, permanent housing subsidies almost halved rates of child separation and more than halved rates of foster care placements; the other interventions did not affect separations significantly. Predictors of separation were primarily homelessness and drug abuse (all comparisons), and alcohol dependence (one comparison). Although housing subsidies reduced homelessness, alcohol dependence, intimate partner violence, and economic stressors, the last three variables had no association with child separations in the subsidy comparison; thus subsidies had indirect effects via reductions in homelessness. No intervention reduced partner separations.

Critical Time Intervention for Homeless People Making the Transition to Community Living: A Randomized Controlled Trial

To help create an evidence base in Europe for effective interventions that improve the well-being of homeless people, we tested whether critical time intervention (CTI), a time-limited intervention developed to support vulnerable people during times of transition, is effective outside the United States. For this multicenter, parallel-group randomized controlled trial, 183 adults who were moving from shelters in the Netherlands to supported or independent housing were allocated to CTI or care-as-usual. The primary outcome was number of days rehoused, which was assessed by interviewing participants four times during a 9-month follow-up. Outcomes were analyzed with three-level mixed-effects models. The primary outcome did not differ between groups. CTI had a significant effect on family support and, for people experiencing less social support, psychological distress. Groups did not differ significantly on social support, fulfillment of care needs, quality of life, self-esteem, excessive alcohol use, or cannabis use. Because few participants were homeless at 9 months, more research is needed to establish whether CTI can prevent long-term recurrent homelessness. Given recent emphasis on informal support in public services and positive effects of CTI on family support and psychological distress, CTI is a fitting intervention for Dutch shelter services.

Housing and Child Welfare: Emerging Evidence and Implications for Scaling up Services

Inadequate housing threatens family stability in communities across the United States. This study reviews emerging evidence on housing interventions in the context of scale-up for the child welfare system. In child welfare, scale-up refers to the extent to which fully implemented interventions sustainably alleviate family separations associated with housing instability. It incorporates multiple aspects beyond traditional measures of effectiveness including costs, potential reach, local capacities for implementation, and fit within broader social services. The framework further encompasses everyday circumstances faced by service providers, program administrators, and policymakers who allocate resources under conditions of scarcity and uncertainty. The review of current housing interventions reveals a number of systemic constraints for scale-up in child welfare. Reliance on rental assistance programs limits capacity to address demand, while current practices that target the most vulnerable families may inadvertently diminish effectiveness of the intervention and increase overall demand. Alternative approaches that focus on homelessness prevention and early intervention must be tested in conjunction with community initiatives to increase accessibility of affordable housing. By examining system performance over time, the scalability framework provides an opportunity for more efficient coordination of housing services within and outside of the child welfare system.

"I'M OPENING MY ARMS RATHER THAN PUSHING AWAY:" PERCEIVED BENEFITS OF A MINDFULNESS-BASED INTERVENTION AMONG HOMELESS WOMEN AND YOUNG CHILDREN

Family homelessness is associated with adverse outcomes in mothers and their young children. Evidence-based programs are needed to support the socioemotional needs of these families. The purpose of this qualitative study was to explore the perceived benefits of participating in a mindfulness program in mother-child dyads receiving services at a therapeutic nursery serving homeless children under the age of 3 years. A convenience sample of 17 predominantly African American mothers participated in in-depth qualitative interviews. Four themes were derived from the data regarding the perceived benefits of the mindfulness program: "me" time, maternal self-regulation, dyadic connectedness, and child well-being. Results demonstrate the perceived benefits of mindfulness on the parent-child relationship and have important implications for families at an increased risk of adverse outcomes. Because homelessness and residential instability confer considerable risk for young children, interventions to support effective parenting are critical.

The Association Between Shelter Rules and Psychosocial Outcomes Among Homeless Youth Residing in Family Shelters

Despite growing numbers of homeless youth living in shelters with caregivers, little research has explored the impact of the shelter environment on emotional well-being. As such, this study assesses the relationship between shelter rules and two psychosocial outcomes among youth in New York City family shelters. Additionally, the direct effect of trauma and the moderating effect of difficulty following shelter rules on psychosocial outcomes was assessed. Youth with difficulty following shelter rules reported significantly more depressive symptoms, but less substance use. Trauma was found to be associated with increased depression and substance use. Difficulty following shelter rules was found to moderate the association between trauma and substance use. Recommendations for future interventions and the creation of shelter policies are discussed.

Describing Trajectories of Homeless Service Use in Hawai'i Using Latent Class Growth Analysis

The State of Hawai'i, like many other areas across the United States, has large numbers of individuals and families experiencing homelessness, many of whom seek support through statewide shelters and services. This study explored the diversity of ways in which individuals and families moved through Hawai'i's homeless service system. Using administrative data, a cohort of new service users was tracked across time to trace the developmental trajectories of their homeless service use. The sample consisted of adults who had entered the service system for the first time in the fiscal year (FY) of 2010 (N = 4655). These individuals were then tracked through the end of FY 2014, as they used emergency shelter, transitional shelter, and outreach services. A latent class growth analysis was conducted and identified four distinct patterns of service use: low service use (n = 3966, 85.2%); typical transitional shelter use (n = 452, 9.7%); atypical transitional use (n = 127, 2.7%), and potential chronic service use (n = 110, 2.4%). Multinomial logistic regression models were then used to determine if select demographic, family, background experience (e.g., education, employment), or health variables were associated with class membership. The distinct profiles for class membership are discussed.

Online Versus Face-To-Face Training of Critical Time Intervention: A Matching Cluster Randomized Trial

This study examined the effectiveness of online education to providers who serve people experiencing homelessness, comparing online and face-to-face training of Critical Time Intervention (CTI), an evidence-based case management model. The authors recruited 184 staff from 19 homeless service agencies to participate in one of two training conditions: (a) Online Training + Community of Practice or (b) Face-to-Face Training + Telephone Consultation. Each group received 24 hours of instruction and support. Through baseline, follow-up, and nine-month post-training surveys, the authors examined satisfaction, knowledge gains, knowledge retention, and readiness to implement CTI. While satisfaction rates were higher among participants in the face-to-face group, the two training conditions produced comparable pre/post knowledge gains. Furthermore, both groups showed increased knowledge retention scores at nine-month follow up, with the online group scoring higher than the face-to-face group.