a systematic review for homeless persons

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Effectiveness of Case Management for Homeless Persons:A Systematic Review

We reviewed the literatureon standard case manage-ment (SCM), intensive casemanagement (ICM), asser-tive community treatment(ACT), and critical time in-tervention(CTI) forhomelessadults. We searched data-bases for peer-reviewedEnglish articles publishedfrom 1985 to 2011 and found21 randomized controlled trialsor quasi-experimental stud-

ies comparing case man-agement to other services.

We found little evidencefor the effectiveness of ICM.SCM improved housing sta-bility, reduced substanceuse, and removed employ-ment barriers for substanceusers. ACT improved hous-ing stability and was cost-effective for mentally ill anddually diagnosed persons.CTI showed promise forhousing, psychopathology,and substance use and wascost-effective for mentally illpersons.

More research is neededon how case managementcan most effectively supportrapid-rehousing approachesto homelessness. ( Am J Public Health. 2013;103:e13e26. doi:10.2105/AJPH.2013.301491)

Rene de Vet, MSc, Maurice J. A. van Luijtelaar, MSc, Sonja N. Brilleslijper-Kater, PhD, Wouter Vanderplasschen,PhD, Marille D. Beijersbergen, PhD, and Judith R. L. M. Wolf, PhD

HOMELESSNESS IS A SERIOUS

and widespread public health problem. In the United States andEurope, estimates for the lifetime prevalence of homelessness range between 5.6% and 13.9%.1 Theglobal nancial crisis has nega-tively affected the prevalence of homelessness. In the United States,

certain groups, such as familiesand people living in suburbanand rural areas, have becomemore vulnerable to homeless-ness.2 In Europe, austerity mea-sures implemented after the start of the crisis have increased pov-erty and homelessness, with pos-sibly the worst to come becauseof a strong time lag effect.3

Homelessness is often accom- panied by other problems. People

who are homeless experiencea lower quality of life than thosewho are domiciled.4,5 Severallongitudinal studies have foundthat quality of life improves asindependent housing is obtained.5---7

Societal participation is limited;many homeless persons are un-employed, have few sources of in-come, and have a limited socialnetwork. They often experienceextreme poverty and a lack of social support.8,9 Although few arefelony offenders, homeless personsare at risk of arrest for transgres-sions resulting from their lifestyle(e.g., panhandling, public intoxica-tion, squatting, and failing to pay

nes).8,10 Moreover, estimates sug-gest that almost 40% of homeless people are dependent on alcoholand 25% on drugs. Many suffer from a mental disorder, such asa psychotic illness (13%), major

depression (11%), or personalitydisorder (23%).11 Physical health problems are more prevalent among this group than in thegeneral population.12,13 Recent studies found that up to 73% of homeless individuals have unmet health needs.14,15 Consequently, homelessness should be regarded

as a signi cant and increasing threat to public health, whichshould be addressed.

In recent years, the focus of policy measures to reduce home-lessness has changed. The Home-less Emergency and Rapid Transi-tion to Housing Act, an amendment to the McKinney---Vento HomelessAssistance Act, was enacted in2009 to modernize the US De- partment of Housing and Urban

Development

s homelessness as-sistance programs.16 In 2010, the jury recommendations of the Eu-ropean Consensus Conference onHomelessness laid out a road mapfor ending homelessness in theEuropean Union.3 Both proposalscalled for a shift away from the"staircase" approach, which re-quires homeless persons to prove housing readiness while transfer-ring through shelters and transi-tional housing situations beforethey become eligible for indepen-dent housing. The proposed alter-native is a rapid-rehousing,16 or housing-led,3 approach, which fo-cuses on providing access to per-manent independent housing asthe initial response to resolving situations of homelessness, in con- junction with exible support ser-vices as required by the serviceneeds of those who are rehoused

to prevent recurrent homeless-ness.17 Case management has beenidenti ed as a strategy to support rapid rehousing, especially for those with complex needs.3 Littleis known, however, about what patterns of services are most suitable to accompany housing for different subgroups of home-

less people.16,18Since the 1980s, several models

of case management have beendeveloped that provide the same basic functions: outreach, assess-ment, planning, linkage, monitor-ing, and advocacy.19,20 Servicesdelivered by case managers ofteninclude practical support, help withdeveloping independent living skills, acute care in crisis situa-tions, support with medical and

psychiatric treatment, and assis-tance with contacts between cli-ents and people in their social and professional support systems.20

We focused on 4 models of case management that have beenrecommended and widely imple-mented for homeless persons19 :standard case management (SCM),intensive case management (ICM),assertive community treatment (ACT), and critical time inter-vention (CTI). The models aredistinguished by the functionsthey emphasize (Table 1). SCM isa coordinated and integrated approach to service delivery, withthe goal to provide ongoing sup- portive care.21 ICM is typicallytargeted to individuals with thegreatest service needs and pre-scribes more intensive services,more frequent client contact, andsmaller individual caseloads than

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does SCM.22 ACT is closely re-lated to ICM; however, in ACTthe responsibility for providing services to clients is shared bya multidisciplinary team that isaccessible 24 hours a day, 7 daysa week.23 CTI is an intensivetime-limited case management approach to enhance continuityof care by bridging the gap be-tween services and strengthening clients social and professionalnetworks. CTI is designed to be

deployed at critical moments inthe lives of clients, for instance,when a person is about to makea transition from a shelter to in-dependent housing.24

To our knowledge, 4 reviewson the effectiveness of case man-agement for homeless adults have been published.19,25---27 All 4 re-views underscore the effectivenessof ACT in producing positiveoutcomes for homeless people.Nevertheless, whether ACT iseffective for all homeless sub-groups in achieving more positiveoutcomes than other services, in-cluding other case management models, remains to be seen. Thesereviews have limitations: (1) theyfocus solely on homeless indi-viduals with severe mental ill-ness,25---27 (2) they examine only1 or 2 of the 4 models in use26,27

or do not distinguish between

different models and their individ-ual effects,25 and (3) they consider only certain outcomes.25,26 Morse provides a more complete over-view; however, he did not conduct a systematic literature search andfailed to describe inclusion criteria for studies. Furthermore, this re-view is dated and was not pub-lished in a peer-reviewed journal.19

Our primary goal was to ex-amine the consistency of ndingsacross various models of case

management and their applicabilityin a variety of homeless subgroupsand settings through a completeoverview of the existing literatureon the effectiveness of the 4 casemanagement models. We catego-rized and evaluated all outcomemeasures that were included inrandomized controlled trials andquasi-experimental studies comparing these models to other ser-vices for the general homeless population or speci c homelesssubgroups.

METHODS

We conducted an electronic systematic literature search for peer-reviewed articles publishedin English between January 1985and June 2011 in the PsycINFO,MEDLINE, Cochrane Library,Embase, and CINAHL databases.

To identify study populationsthat were predominantly home-less, we used the following key-words: homeless, homelessness,

and homeless people. We com- bined these keywords with thefollowing terms to search for the4 case management models: strengths-based, strengths perspective, case manage-ment, intensive case manage-ment, assertive communitytreatment, critical time inter-

vention,

outreach,

outreach programs, mental health,

mental illness, psychiatric ,

and substance abuse (Appendix A, Table A, available as a supple-ment to this article at http://www.ajph.org ). We used Web of Sciencefor a cited reference search.

After we conducted the search,we removed duplicates, and 2 re-viewers independently screened ti-tles and abstracts of the retrieved publications. We excluded reportsthat did not match our inclusioncriteria, and 2 other reviewersindependently evaluated theremaining publications. We re-solved disagreements throughdiscussion among at least 3 re-viewers to achieve consensus.

Selection Criteria

Participants in eligible studysamples were aged 18 years or

older. The recruitment strategy of the study had to target a predomi-nantly homeless population, asevidenced by the description of the target population, recruitment setting, or selection criteria. For the purpose of our review, wede ned homeless persons as

1. persons who lacked a xed,regular, and adequate night-time residence or resided at night in a place not meant for

human habitation;2. persons who were living in

a shelter;3. persons who were exiting an

institution and resided in a shelter or place not meant for human habitation before insti-tution entry;

4. persons who would imminentlylose their housing and lackedthe resources to obtain other permanent housing;

5. unaccompanied youths or homeless families with childrenwho experienced unstable housing; and

6. persons who were eeing dan-gerous conditions in their cur-rent housing situation andlacked the resources to obtainother permanent housing.28

We imposed no restrictionsregarding other participant

TABLE 1Characteristics of Case Management Models for Homeless Adults

Standard Case Management21 Intensive Case Management21,22 Assertive Community Treatment21,23 Critical Time Intervention21,24

Focus of services Coordination of services Comprehensive approach Comprehensive approach Targeted to continui ty of care

Target population Homeless persons Homeless persons with the greatest

service needs

Homeless persons with the greatest

service needs

Homeless persons at critical

transitions in their lives

Duration of services Time limited Ongoing Ongoing Time limited

Average caseload, no. 35 15 15 25

Outreach No Yes Yes Yes

Coordination or service provision Coordination Service provision Service provision Service provision and coordination

Responsibility for clients care Case manager Case manager Multidisciplinary team Case manager

Importance of clientcase

manager relationship

Somewhat important Important Important Important

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characteristics, such as being el-derly, suffering from a mental ill-ness, or having a military service history.

The title or abstract had toindicate that the study includedan intervention. In the full-text article, at least 1 of the includedinterventions had to be identi edas adhering to, or being based on,1 of the 4 models of case man-agement that we selected. Fur-thermore, the study had to bedesigned as a randomized con-trolled trial or a before-and-after study, incorporating a baselineand at least 1 follow-up assess-ment of outcome variables,comparing 2 or more groups that received different interventions.The article had to include participant-level outcomes . Be-cause our aim was to providea complete overview of all pre-viously reported effects, we didnot limit our selection to prese-lected outcomes of interest or im- pose restrictions regarding theservices received by participants

in control groups or length of follow-up.

Study Quality and DataExtraction and Synthesis

Two reviewers critically ap- praised the selected publicationsindependently with criteria for grading internal validity derivedfrom the US Preventive ServicesTask Force Methods WorkGroup,29 by which evidence isclassi ed as good, fair, or poor.We derived cutoff points for sample size, retention rate, andoverall rating from Hwang et al.30

and Altena et al.31 (Appendix B,Tables B and C, available as a supplement to this article at http://www.ajph.org ).

Because we expected participants, settings, control group ser-vices, and outcome measures todiffer markedly between studies,

we could not conduct a meta-analysis. Instead, we focused onnarrative descriptions of the evi-dence, with the goal to examine

patterns across studies, provideinformation about applicabilityof results, and consider multipleexplanations for differential

ndings across studies. Weadapted the effect direction plot by Thomson and Thomas to prepare a visual summary of effect direction for all reported participant-level outcomes toaccompany the narrativesynthesis.32

We rst grouped the selected publications according to casemanagement model and thenaccording to study sample. Onereviewer performed the data extraction, which a second re-viewer checked. In addition toall participant-level outcomes, weextracted details of the interventionimplementation, target popula-tion, recruitment setting, samplesize, study design, and length of follow-up. We next tabulated

outcome data and grouped theminto 7 outcome domains derivedfrom the extracted outcomemeasures, through a bottom-upapproach. The 7 outcome do-mains, 4 of which were further divided into several outcomecategories, were

1. service use (services provided by program staff and nonpro-gram inpatient, emergency, andoutpatient services),

2. housing,3. health (physical and mental),4. substance use (alcohol and

drugs),5. societal participation (economic

participation---security, criminalactivity---legal problems, andsocial behavior---support),

6. quality of life, and7. cost (service expenses and

cost-effectiveness).

We determined the direction of effect impact (negative, positive,none, or unclear) and the level of statistical signi cance (P .05) for

each extracted outcome measure(Appendix C, Tables D---J, availableas a supplement to this article at http://www.ajph.org ). We further synthesized the data to producea single indication of overall impact in each outcome category for each publication, combining 2 or more measures where more than1 outcome was reported for anyoutcome category. We usedseveral synthesis techniques, suchas tabulation, vote counting (asa descriptive tool), and concept mapping, in an iterative process asrecommended by Popay et al. toconduct a narrative synthesis of the research-based evidence fromthe selected articles.33

RESULTS

The results of the systematic search and selection process aresummarized in Figure 1. We re-

trieved 3721 publications. Our review of titles and abstractsidenti ed 133 publications that seemed to meet our criteria. Full-text versions of 5 publicationscould not be obtained, even byrequesting them from librariesabroad or contacting the authorsdirectly. Further examinationof 128 full-text publicationsrevealed that 33 satis ed our criteria for inclusion.34---66 Inter-rater agreement for publication se-lection was moderate (Cohen j =0.49). Failing to include any of the 4 case management modelsas an experimental interventionwas the most common reason for exclusion. Other publications hadto be excluded because participants were not predominantly homeless or were younger than18 years or because the studiesdescribed lacked a randomized

or quasi-experimental design.Initially, we intended to includein our review strengths-basedcase management (SBCM), a

model that emphasizes empow-erment, self-direction, and therelationship between client andcase manager,67,68 but none of the publications that met our selection criteria studied SBCM.Therefore, we could only report results of studies on SCM, ICM,ACT, and CTI. Several publi-cations reanalyzed previously published data, and others con-tained results from more than 1research site; the 33 publications pertained to 21 unique studysamples.

Study QualityAgreement between reviewers,

derived from the quality-rating items for a subsample of 6 arti-cles, was substantial (weightedCohen s j = 0.64). Of the 33 in-cluded publications, we rated 17as having good internal validity,15 as fair, and 1 as poor (Ap-

pendix B, Table C). The publica-tion with a poor rating omittedimportant information about thestudy design. We were unableto determine whether compara- ble groups were assembled at baseline, whether groups suf-fered from differential attrition,whether valid and reliable mea-surement instruments were usedand applied equally among groups,and whether an intention-to-treat analysis was performed.42

Shortcomings encountered instudy designs rated as fair wereimprecisely de ned interven-tions,37 assembly of unequalgroups,37,38 and loss to follow-upof more than half of the sampleor failure to report follow-uprates.44,54,66 Other limitationswere failing to maintain compa-rable groups during follow-up,37,43,54,60,62 failing to report

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details of measurement proce-dures and to adequately blindobservers who assessed out-comes,35---39,41,48,66 and neglect-ing to perform an intention-to-treat analysis and to control for keyconfounders.35,39,43,45,52,62 Weconsidered methodological limi-tations that could increase therisk of bias in our analysis.

Study CharacteristicsCharacteristics of included

studies are shown in Table 2.Fourteen publications were issued

in 1999 (when the review byMorse was published19 ) or later. Of the 21study samples, 20 wererecruited in the United States and1 in the United Kingdom. Thesample sizes ranged from 80 to722 participants; the total samplesize was 5618 participants.Varying de nitions of homeless persons were employed acrossstudies, and various homelesssubgroups could be discerned:literally homeless persons, per-sons at risk for homelessness, homeless veterans, homeles s

ex-prisoners, homeless substanceusers, homeless persons with se-vere mental illness, and homeless persons with co-occurring mentaland substance use disorders (dualdiagnoses). These subgroups rep-resent the large variety of re-cruitment settings where poten-tial participants were approached.Because control group servicesoften consisted of the usual care provided in a particular setting,services received by participantsin control groups were also di-verse (Table 2).

Outcome measures also variedwidely between studies. Fre-quently, different instrumentswere used to measure the same

outcome (Appendix C, Tables D---J).Table 3 presents the overall impact in each outcome category for each publication, combining 2or more measures where morethan 1 outcome was reported (a visual interpretation of thesynthesisis available as a supplement to thisarticle at http://www.ajph.org ).

Service UseThe 2 studies of SCM that

examined service utilizationdetected few differences be-tween SCM and the controlconditions.35,36 In a sample of substance-dependent homelessveterans, SCM participants re-ceived more support from pro-gram staff and other participantsand were better prepared for program completion than par-ticipants in the control pro-gram.35 However, SCM did not increase the use of other Vet-

erans Affairs services, as had been expected at the outset of this study. With the exceptionof reporting more substanceabuse treatment at the 3-monthfollow-up, SCM participantsreported similar service use ascontrols.35 In line with these

ndings, a second study showedthat SCM for mentally ill peoplewho were homeless or margin-ally housed did not signi cantlyaffect participants needs for psy-chiatric and social care or reducethe length of hospital stays.36

Two studies, both of whichexamined samples of homeless people with substance use prob-lems, compared the services of-fered by ICM programs to usualcase management services. Partic-ipants recruited from a homelessshelter who received ICM weremore satis ed than control

Records identi ed through database searching (n = 17 293)Records identi ed November 57, 2008MEDLINE (n =3907), PsycINFO (n=5460), The Cochrane Library (n=422), Embase(n = 3250), CINAHL (n = 1705)Records identi ed March 19, 2010

MEDLINE, PsycINFO, The Cochrane Library, Embase, and CINAHL (n= 1454)Records identi ed June 67, 2011MEDLINE, PsycINFO, The Cochrane Library, Embase, and CINAHL (n= 1095)

S c r e e n

i n g

I n c

l u d e

d

E l i g

i b i l i t y

I d e n

t i c a

t i o n

Records identi ed through citedreference search

(n = 460)

Publications included in qualitative synthesis(n= 33)

Methodological quality of publications:rating of good (n= 17), fair (n= 15), or poor

(n=1)

Not a peer-reviewed article (n=11)

Full-text publications excluded (n = 100) Selected case management models not included as experimental intervention (n= 67) Participants not predominantly homeless (n= 13)

Full-text version not available (n=5) Lack of randomized or quasi-experimental design (n= 3) Participants younger than 18 years (n=1)

Full-text publications assessed for eligibility(n= 133)

Records excluded basedon title and/or abstract

(n=3588)Records screened(n=3721)

Duplicates removed(n = 14 032)

Total number of records identi ed(n= 17753)

FIGURE 1Summary of database search and study selection in review of literature on models of casemanagement for homeless adults, 19852011.

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T A B L E 2

C o n

t i n u e

d

H o m e l e s s m e n w i t h

s t a b l e m e n t a l h e a l t h

a n d a p r o b l e m w i t h

a l c o h o l o r d r u g u s e

M e n s h o m e l e s s s h e l t e r ,

P h i l a d e l p h i a , P A

R C T

S h e l t e r - b a s e d i n t e n s i v e c a s e

m a n a g e m e n t

1 : I n t e g r a t e d c o m p r e h e n s i v e

s e r v i c e s b y r e s i d e n t i a l

t r e a t m e n t f a c i l i t y , 2 : u s u a l

c a r e s h e l t e r s e r v i c e s ( c a s e

m a n a g e m e n t )

9 m o / 1 : 6 m o

, 2 :

n o n s p e c i c

1 5

t o 1 / 1 : N A , 2 : 5 0

7 5 t o 1

2 0 0 / 1 : 2 2 0

, 2 :

3 0 2

S t a h l e r

e t a l . 4

3

H o m e l e s s p e o p l e

L o c a l h u m a n s e r v i c e

a g e n c i e s ( s h e l t e r s , s o u p

k i t c h e n s , c r i s i s a n d

h o u s i n g a s s i s t a n c e

s e r v i c e s ) , B u f f a l o

, N Y

R C T

I n t e n s i v e c a s e m a n a g e m e n t F r e e t o s e e k s e r v i c e s i n t h e

c o m m u n i t y

8 m o / N A

N R / N A

1 0 1 / 1 0 1

T o r o e t

a l . 4

4

A s s e r t i v e c o m m u n i t y

t r e a t m e n t

H o m e l e s s p e o p l e w i t h

s e r i o u s m e n t a l i l l n e s s

E m e r g e n c y r o o m s a n d

i n p a t i e n t u n i t s o f t h e

p u b l i c a c u t e c a r e

p s y c h i a t r i c h o s p i t a l , S t

L o u i s

, M O

R C T

1 : A s s e r t i v e c o m m u n i t y

t r e a t m e n t o n l y

, 2 :

a s s e r t i v e c o m m u n i t y

t r e a t m e n t w i t h c o m m u n i t y

w o r k e r s

B r o k e r c a s e m a n a g e m e n t

O n g o i n g / N R

1 0 t o 1 / 8 5 t o 1

1 6 5 i n t o t a l

B u r g e r e t a l . ,

4 5

C a l s y n

e t a l .

( s t u d y 2 ) ,

4 6

M c B r i d e e t a l . ( s t u d y

2 ) ,

4 7

M o r s e e t a l .

, 4 8

W o l f f e t a l . 4

9


a s e v e r e m e n t a l i l l n e s s

L o c a l e m e r g e n c y s h e l t e r s

, S t

L o u i s

, M O

R C T


t r e a t m e n t

1 : D a y t i m e d r o p - i

n c e n t e r

( a s s i s t a n c e b y s o c i a l

w o r k e r s ) , 2 : o u t p a t i e n t

t r e a t m e n t ( o f c e - b

a s e d

o u t p a t i e n t t h e r a p y ,

m e d i c a t i o n

, a n d

a s s i s t a n c e w i t h s o c i a l

s e r v i c e s )

O n g o i n g / 1 : N R

, 2 : N A

1 0 t o 1 / 1 : 4 0 t o 1

, 2 : N A

5 2 / 1 : 6 2

, 2 : 6 4

C a l s y n e t a l . ( s t u d y

1 ) ,

4 6

M c B r i d e e t a l .

( s t u d y

1 ) ,

4 7

M o r s e

e t a l .

5 0


s e v e r e m e n t a l i l l n e s s

a n d s u b s t a n c e u s e

d i s o r d e r

V a r i e t y o f s e t t i n

g s

( e m e r g e n c y s h e l t e r s

,

p s y c h i a t r i c h o s p i t a l s

,

s t r e e t l o c a t i o n s f r e q u e n t e d

b y h o m e l e s s p e r s o n s ) , S t

L o u i s

, M O

R C T

1 : I n t e g r a t e d a s s e r t i v e

c o m m u n i t y t r e a t m e n t b y

c o m m u n i t y m e n t a l h e a l t h

a g e n c i e s

, 2 : a s s e r t i v e

c o m m u n i t y t r e a t m e n t o n l y

b y c o m m u n i t y m e n t a l

h e a l t h a g e n c i e s

S t a n d a r d c a r e ( l i n k a g e

a s s i s t a n c e t o a c c e s s

c o m m u n i t y s e r v i c e s )

N R / N A

N R / N A

1 : 6 1

, 2 : 6 5 / 6 5

C a l s y n e t a l .

, 5 1

F l e t c h e r

e t a l . ,

5 2

M o r s e e t a l

. , 5 3

M o r s e

e t a l

. 5 4

H o m e l e s s v e t e r a n s w i t h

a s u b s t a n c e a b u s e

d i s o r d e r

, d u a l d i s o r d e r

,

o r p s y c h i a t r i c d i s o r d e r

V A m e d i c a l c e n t e r s

, S a n

F r a n c i s c o a n d

S a n D i e g o

,

C A ; N e w O r l e a n s

, L A ; a n d

C l e v e l a n d

, O H

R C T

1 : M o d i e d a s s e r t i v e

c o m m u n i t y t r e a t m e n t b y

V A c a s e m a n a g e r s

, 2 :

m o d i e d a s s e r t i v e

c o m m u n i t y t r e a t m e n t w i t h

s p e c i a l a c c e s s t o h o u s i n g

s u b s i d i e s

S t a n d a r d V A h o m e l e s s

s e r v i c e s ( b r o k e r c a s e

m a n a g e m e n t )

N R / s h o r t t e r m

2 5 t o 1 / N R

1 : 9 0

, 2 : 1 8 2 / 1 8 8

C h e n g e t a l .

, 5 5

R o s e n h e c k e t a l

. 5 6

C o n

t i n u e

d

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participants, although a minority(29%) of the ICM participantscompleted the program.43 In theother study, participants recruited

at a medical van who wereassigned to the ICM group hadsigni cantly more contacts withthe medical van s case manager than did control participants,who had the opportunity for self-referral to the same casemanager. 42 Although these 2studies found that program ser-vices signi cantly differed be-tween conditions, ndings from3 other studies on the impact of ICM on nonprogram service uti-lization were mixed.

The number of days spent in psychiatric hospitals by homelessmentally ill people did not differ between ICM and control participants.41 Among homeless sub-stance users, ICM did not havea signi cant differential effect onthe number of days spent inresidential treatment facilities or the number of in- and outpatient services received.39 We found

some evidence, however, that ICM was more effective thanstandard detoxi cation treatment in reducing subsequent detox admissions.40

Six studies, as reported in 8articles, compared the servicesreceived by ACT and control par-ticipants.48---50,52---54,56,60 Thesestudies indicated that, for severaldifferent homeless subpopulations,ACT increased contacts between participants and case managers or other program staff,48---50,53,54,56,60

enhanced the level of assistancedirectly provided by programstaff,48,53,56 and improved participant satisfaction.48---50,52,53

One article, which reportedndings from 2 studies with se-

verely mentally ill homeless par-ticipants, showed that participants in the ACT programs hadrelatively larger professional

T A B L E 2

C o n

t i n u e

d

H o m e l e s s o r u n s t a b l y

h o u s e d p e o p l e w i t h

s e v e r e m e n t a l i l l n e s s ,

s u b s t a n c e u s e d i s o r d e r ,

h i g h s e r v i c e u s e

, a n d

p o o r i n d e p e n d e n t l i v i n g

s k i l l s

T w o s t a t e

- o p e r a t e d

o u t p a t i e n t c o m m u n i t y

m e n t a l h e a l t h

c e n t e r s

,

C o n n e c t i c u t

R C T

I n t e g r a t e d a s s e r t i v e

c o m m u n i t y t r e a t m e n t

I n t e g r a t e d s t a n d a r d c l i n i c a l

c a s e m a n a g e m e n t

N R / N R

1 0

1 5 t o 1 / 2 5 t o 1

9 9 / 9 9

E s s o c k e t a l .

5 7


s e v e r e

, p e r s i s t e n t

m e n t a l i l l n e s s

, m o s t

w i t h d u a l d i a g n o s e s

I n n e r - c i t y p s y c h

i a t r i c

h o s p i t a l s a n d

c o m m u n i t y

a g e n c i e s f o r h o m e l e s s

p e o p l e

, B a l t i m

o r e

, M D

R C T


t r e a t m e n t

U s u a l c o m m u n i t y s e r v i c e s

( g e n e r i c c a s e m a n a g e m e n t

s e r v i c e s )

O n g o i n g / N R

1 0

1 2 t o 1 / N R

7 7 / 7 5

L e h m a n e t a l .

, 5 8

L e h m a n e t a l .

5 9

H o m e l e s s a n d s e r i o u s l y

m e n t a l l y i l l p e o p l e

b e i n g r e l e a s e d f r o m j a i l

J a i l s y s t e m o f a l a r g e U S

u r b a n c e n t e r

R C T


t r e a t m e n t b y t e a m o f

f o r e n s i c c a s e m a n a g e r s

1 : I n t e n s i v e c a s e

m a n a g e m e n t b y i n d i v i d u a l

f o r e n s i c c a s e m a n a g e r s

, 2 :

r e f e r r a l t o a f t e r c a r e b y

c o m m u n i t y m e n t a l h e a l t h

c e n t e r s

1 y / 1 : N R

, 2 : N A

N R / N R

6 0 / 1 : 6 0

, 2 : 8 0

S o l o m o n e t a l .

6 0

C r i t i c a l t i m e i n t e r v e n t i o n

S e v e r e l y m e n t a l i l l

p e o p l e l e a v i n g a m e n s

s h e l t e r

O n - s

i t e p s y c h i a t r y p r o g r a m

i n a m e n s s h e l t e r , N e w

Y o r k

, N Y

R C T


U s u a l s e r v i c e s o n l y ( r e f e r r a l

t o c o m m u n i t y a g e n c i e s )

9 m o / N A

N R / N A

4 8 / 4 8

H e r m a n

e t a l .

, 6 1

J o n e s

e t a l . ,

6 2

J o n e s e t a l

. , 6 3

L e n n o

n e t a l .

, 6 4

S u s s e r e t a l .

6 5

R e c e n t l y o r i m m i n e n t l y

h o m e l e s s v e t e r a n s w i t h

s e r i o u s m e n t a l i l l n e s s

I n p a t i e n t u n i t s

o f V A

m e d i c a l c e n t e r s , C h i c a g o

a n d H i n e s , I L ; H o u s t o n

, T X ;

L y o n s , N J ; M o n t r o s e

, N Y ;

R i c h m o n d a n d S a l e m

, V A ;

a n d S a n D i e g o

, C A

H C T


U s u a l d i s c h a r g e p l a n n i n g

s e r v i c e s b y i n p a t i e n t u n i t

s t a f f a n d s t a n d a r d r e f e r r a l

t o o u t p a t i e n t s e r v i c e s

6 m o / N A

1 5 t o 1 / N A

2 0 6 / 2 7 8

K a s p r o w e t a l .

6 6

N o t e

. C B A = c o n t r o l l e d b e f o r e - a

n d

- a f t e r s t u d y ; H C T =

h i s t o r i c a l l y c o n t r o l l e d t r i a l ; N A = n o t a p p l i c a b l e ; N R = n o t r e p o r t e d ; Q

- R C T = q u a s i - r

a n d o m i z e d c o n t r o l l e d t r i a l ; R C T = r a n d o m i z e d c o n t r o l l e d t r i a l ; V A =

V e t e r a n s A f f a i r s .

a T h

i s p r o g r a m e m p l o y e d a d y a d s t r u c t u r e

, w i t h p a i r s o f c a s e m a n a g e r s s h a r i n g c a s e l o a d s .

SYSTEMATIC REVIEW



8/15


9/15

networks. 46 In 1 of these samesamples, Morse et al. found that ACT participants also had morecontacts with service agencies

than did control participants.50

In a reexamination of the other sample, however, Wolff et al.found no signi cant differentialeffects with regard to in- or outpatient services for these men-tally ill homeless participants.49

This reanalysis may have lackedsuf cient power or may have been biased by differential attri-tion, because service utilizationdata were available for approxi-mately half of the original sample.

For participants with dualdiagnoses, we found evidence that ACT is effective in shortening thelength of psychiatric hospitalstays57---59 and reducing thenumber of emergency room visitsfor mental health problems. 58,59

ACT was not found to signi -cantly reduce other inpatient service use by these participants,such as inpatient medical care, 58,59

residential substance abuse treat-

ment,58,59

or mental health reha- bilitation.59 Two articles on thesame study reported that ACT participants with dual diagnosesvisited outpatient mental healthservices and substance abusetreatment more often than par-ticipants receiving generic casemanagement services. 58,59

Among substance-using home-less veterans, however, ACT didnot have a differential effect onoutpatient service use. 56

None of the articles examinedthe differences between programservices provided by CTI andcontrol conditions. Preliminaryresults indicated that CTI in-creased use of nonprogram outpatient services. 62 In another study, CTI reduced the length of hospital and other insti tutionalstays for mentally ill homelessveterans. 66

HousingOf 5 studies examining the im-

pact of SCM on housing stability,3, all reporting on homeless sub-

stance users, showed statisticallysigni cant effects.34,37,38 The 2studies that did not nd a positiveimpact of SCM on housing out-comes differed in several impor-tant ways. In 1 study, high-risk participants in the sample of homeless substance users wereall assigned to the SCM condition,which as implemented did not differ in type or intensity of ser-vices from the control condition. 37

In the other, the sample consistedof mentally ill people instead of substance users, and sample sizeof 80 may have provided insuf-

cient power to reveal a signi cant difference between groups in the housing variables.36

Seven studies of ICM producedmixed results on housing out-comes. Of the 5 studies investi-gating the effects of ICM on homelessness or residential stability in substance-abusing popu-lations,37,39,40,42,43 1 reporteda signi cantly better result for ICM than for the control condi-tion.40 These mostly nonsigni -cant ndings could have beenattenuated by treatment nonadherence and lack of differentialservice utilization between groups.For example, 71% of participantsassigned to shelter-based ICMservices for substance-using homeless men did not completethe program. 43

The 2 studies of ICM that didnot examine homeless substanceusers showed a positive impact on housing. In a study with se-verely mentally ill participants,ICM signi cantly improved hous-ing stability.41 In a more heteroge-neous sample of homeless persons, participants receiving ICM experi-enced better living conditions

T A B L E 3

C o n

t i n u e

d

S o l o m o n e t a l . 6

0

F a i r

M i x e d

3

N o d i f f e r e n c e

C r i t i c a l t i m e

i n t e r v e n t i o n

H e r m a n e t a l . 6

1

G o o d

M i x e d

3

J o n e s e t a l

. 6 2

F a i r

M i x e d

b 3


b 3

M i x e d

b 6

M i x e d

b 3

M i x e d

b 2

J o n e s e t a l

. 6 3

G o o d

P o s i t i v e

3


4


2 1

M i x e d

6

L e n n o n e t a l

. 6 4

G o o d

P o s i t i v e

a

S u s s e r e t a l . 6

5

G o o d

M i x e d

6

K a s p r o w e t a l . 6

6

F a i r

P o s i t i v e a


b

M i x e d

2

P o s i t i v e

a

P o s i t i v e 2

P o s i t i v e 2


2

N o t e

. M i x e d = m i x e d o r c o n i c t i n g s t u d y n d i n g s ; n e g a t i v e =

i n t e r v e n t i o n h a d n e g a t i v e i m p a c t o n o u t c o m e ; n o d i f f e r e n c e =

i n t e r v e n t i o n a n d c o m p a r i s o n s o u t c o m e s w e r e t h e s a m e ; p o s i t i v e =

i n t e v e n t i o n h a d a p o s t i v e i m p a c t o n o u t c o m e . A l l

d i f f e r e n c e s b e t w e e n c o n t r o l a n d i n t e r v e n t i o n g r o u p a t f o l l o w - u

p w e r e s i g n i c a n t a t P

. 0 5 ( u n l e s s o t h e r w i s e i n d i c a t e d ) . S y n t h e s i s o f m u l t i p l e o u t c o m e s w i t h i n s a m e o u t c o m e c a t e g o r y : w h e r e m u l t i p l e o u t c o m e s a l l r e p o r t e d e f f e c t s i n t h e

s a m e d i r e c t i o n

, w e r e p o r t e d t h i s e f f e c t d i r e c t i o n

. W h e r e d i r e c t i o n o f e f f e c t v a r i e d a c r o s s m u l t i p l e o u t c o m

e s ,

w e r e p o r t e d t h e m a j o r i t y e f f e c t d i r e c t i o n i f 7 0 % o f o u t c o m e s r e p o r t e d a s i m i l a r d i r e c t i o n

. I f l e s s t h a n 7 0 % o f o u t c o m e s r e p o r t e d

a c o n s i s t e n t d i r e c t i o n o f e f f e c t

, w e r e p o r t e d t h e e f f e c t d i r e c t i o n a s m i x e d

. W h e r e a v a i l a b i l i t y o f s t a t i s t i c s o r d a t a v a r i e d

, w e c o n s i d e r e d e f f e c t s a s s t a t i s t i c a l l y s i g n i c a n t i f s t a t i s t i c a l s i g n i c a n c e w a s a v a i l a b l e f o r m o r e t h a n 6 0 % o f t h e

o u t c o m e s

. N u m b e r o f o u t c o m e s w i t h i n e a c h c a t e g o r y s y n t h e s i s w a s 1 u n l e s s i n d i c a t e d i n s u b s c r i p t b e s i d e e f f e c t d i r e c t i o n .

a D

i f f e r e n c e i n c h a n g e b e t w e e n c o n t r o l a n d i n t e r v e n t i o n g r o u p

.

b N o s t a t i s t i c s d a t a r e p o r t e d

.

SYSTEMATIC REVIEW



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during follow-up than did control participants.44

Most articles examining theeffect of ACT on housing

outcomes found positive ef-fects.47,48,50,52---54,57,58 Homeless persons with severe mental ill-ness who received ACT spent fewer days homeless or moredays in stable housing than did participants who receiveddrop-in center services, of ce- based outpatient treatment, or less proactive case manage-ment.47,48,50 For homeless par-ticipants with dual diagnoses,ACT programs also improved housing stability more than SCMand other forms of linkage assis-tance.52---54,57,58 As reported in 2articles, 1 study with homelessveterans with substance abusedisorders did not nd a signi -cant positive effect of ACT on housing. For this sample, ACTdid not have a signi cant impact on any of the housing-related out-come measures, unless participants were also supplied with

special access to subsidized hous-ing (Section 8 vouchers).55,56

However, the model integrity of this ACT program was debatable because the case managers hadrelatively high caseloads of 25clients.

Multiple reports examinedCTI housing outcomes in 2 uniquesamples.62---66 For mentally illmen leaving a homeless shelter,adding CTI to community ser-vices for 9 months was effectivein decreasing homeless nights.62---65

Interestingly, the difference be-tween groups became more pro-nounced after the time-limitedintervention had ended. 65 Ina study with homeless veteranswho were leaving inpatient care,CTI signi cantly increased days housed, although the CTI andcontrol groups did not differ innights spent homeless.66

Physical and Mental HealthTwo articles examined the

impact of 3 SCM programs on physical health problems.34,37 In

1 study, the SCM program for homeless substance users, pro-vided in a residential setting, helped to lessen the severity of participants medical problems.34

Two other studies employedsimilar samples and used thesame measurement instrument but did not detect any effects,although results might have beenweakened by attrition bias and program nonadherence. 37 The 4studies that addressed mental health problems did not nda signi cant positive effect of SCM.34,36,37

Homeless substance users didnot bene t from ICM in their physical or mental health in 4studies.37,39,42,43 In a heteroge-neous group of homeless persons,ICM had a positive impact oninterviewer ratings of psychiatric symptom severity.44 Although partic ipants ratings of symptomseverity did not differ betweengroups, ICM participants reportedfewer stressful life events, which have been well established asa predictor of several mentaldisorders, particularly depres-sion.69---71

Because the 3 articles that discussed the impact of ACT on partic ipants physical health gen-erally did not report differentialeffects, little evidence exists that ACT affects this outcome.55,56,58

Two of 6 studies that assessedmental health impacts found sta-tistically signi cant reductionsin psychiatric symptoms.48,58 Ina mentally ill sample, Morse et al.found that interviewer ratingsfor some symptoms were lower for the ACT group, although their unmasked interviewers may have introduced bias.48 Another

study found that homeless par-ticipants with dual diagnosesreported fewer symptoms if they had received ACT.58

A signi cant effect of CTI onthe reduction of psychiatric symptoms was demonstrated in both studies with mental health problems as an outcome.61,66 Noarticle reported inclusion of a physical health measure.

Substance UseFour studies of SCM, whose

participants were homeless peoplewith substance abuse problems,assessed substance use outcomes,as reported in3 articles.34,37,38 All but 1 found differential effects,suggesting that SCM was signi-cantly more effective than referralto community services in reducing alcohol and drug use among homeless substance users.34,37,38

In the 1 study that did not repli-cate these results, all participantsat high risk for relapse wereassigned to the SCM group. More-over, the services received hardly

differed between groups. There-fore, it is not surprising that SCM participants did not reduce their substance use more than control participants.37

Four of 6 studies of the effect of ICM on alcohol or drug use didnotshow a positive impact.37,39,42,44

One study provided some evi-dence that ICM decreased daysdrinking and the severity of al-cohol problems for homelesssubstance users.40 This was con-

rmed by a per-protocol analysisof a second study with a similar sample: program completersreported less alcohol use than didcontrol participants.43 However,2 other studies failed to replicatethese ndings,39,44 and another study s results signi cantly fa-vored the control condition.37

These nonsigni cant and nega-tive results could have been

biased by methodological limita-tions, such as high rate of attri-tion44 and lack of differentiationin services received.37,39

Five studies, which produced8 articles with alcohol and drug use outcomes, concluded that ACT did not signi cantly affect substance use or related prob-lems.48,50,52---57 One study on CTIlooked at substance use vari-ables.66 In a sample of mentallyill homeless veterans, those of-fered CTI improved more withregard to alcohol and drug usethan participants who receivedusual services. Furthermore, part icipants in the CTI groupspent less money on these sub-stances.66

Societal Participation andQuality of Life

Three articles with ndingsfrom 4 studies on SCM includedmeasures related to societal par-ticipation.34,36,37 Two studiesfound that mentally ill or substance-using homeless par-

ticipants who received SCM didnot spend more days in employ-ment.36,37 Homeless substanceusers receiving SCM also did not experience more economic secu-rity,37 although they generallyreported fewer problems that in-terfered with employment.34,37

One study looked at the impact of SCM on the severity of legal problems experienced by home-less substance users and did not

nd a differential effect.34 Ina sample of mentally ill homeless persons, interviewers observedless deviant behavior among SCMthan among control participants,although participants perceptionsof their social behavior and in-terviewer ratings of general func-tioning did not differ betweengroups.36

We found very little evidencethat ICM improved economic

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participation or security, 37,39,40,43,44

reduced criminal activity or legal problems, 39,43 or promoted so-cial behavior or support. 39,43,44

Two studies indicated that ICMcould help homeless substanceusers to access sources of public assistance.40,42 A study witha heterogeneous sample of homeless people, however, didnot yield the same result. 44

Similarly, ACT did not seem to have any impact on economic par-ticipation or security. 48---50,53,55,56

Of 5 studies exploring the effect of ACT on measures of criminalactivity or legal problems,51,56---58,60

1 showed a signi cant differentialeffect: for participants with dualdiagnoses, ACT signi cantly de-creased the likelihood of being incarcerated. 57 In addition, ACTdid not affect variables related tosocial support, except for aneffect on perceived material support at 1 research site. 46 No other differences were found betweenACT and control groups in thesize or quality of participants

social network for 2 samples of mentally ill and 2 samples of homeless people with dualdiagnoses.46,50,55,56

Studies of CTI found no dif-ferential effect regarding days inemployment 66 or income. 63,66

One study found that CTI partic-ipants spent fewer days in jailthan control participants. Thearticle, however, did not report any statistics.62 None of thestudies included measures of so-cial behavior or support as out-comes.

Few studies considered qualityof life as an outcome. One study,on the effectiveness of ACT for homeless persons with dual diag-noses, found a signi cant improvement. 58 ACT participantswere generally more satis ed withlife than those receiving SCM ser-vices at a 6-month follow-up. Over

longer periods of follow-up, how-ever, no evidence was foundfor an effect of ACT on this out-come in samples of dually diag-

nosed homeless persons57,58

or substance-abusing homeless vet-erans. 55,56 Similarly, SCM did not seem to improve the quality of lifeof homeless and marginally housed people with mental disordersrelative to usual community care.In a study with homeless sub-stance users, general life satisfac-tion was higher among control participants, who received usualservices, than among participantswho received ICM.39

Service Costs and Cost-

Effectiveness

No study examined the costsassociated with SCM or ICM. Inline with the differential effectsof ACT on service utilization,studies con rmed that costs for outpatient services, including case management services, were higher for ACT than for standardservices offered by psychiatric

hospitals and agencies serving homeless persons. 49,53,56,59

Costs for inpatient services, however, were lower, which ledLehman et al.59 and Wolff et al. 49

to conclude that their ACT pro-grams were not more expensivethan usual services and achieved better results.

Similarly, the pattern of ser-vice use associated with CTI wasre ected in its cost. Acute mental heal th costs , which includecharges for inpatient and emer-gency services, were lower for CTI than for standard shelter services, although this differencewas not signi cant.63 The onlysigni cant differential effect wasa substantial reduction in shelter costs among CTI participants.63

Jones et al. demonstrated that thecost of resources used by CTI participants did not differ from

the costs for usual care participantsandthat thecostsfor providingCTIwere compensated for by long-term improvements in housing

stability.63

DISCUSSION

Our systematic review is therst to our knowledge to provide

a comprehensive overview of the evidence provided by ran-domized controlled trials andquasi-experimental studies for the effectiveness of 4 models of case management in homeless populations. Because the casemanagement models performthe same functions, they are not mutually exclusive.20 Manystudies we reviewed did not as-certain whether services weredelivered in accordance with thecriteria of the model. We cate-gorized the studies by modelaccording to de nitions pro-vided in the articles; these cate-gories were correct only to theextent that the studies reported

accurate information about themodels.

Except for 1 study conductedin the United Kingdom with se-verely mentally ill people, allstudies concerned with SCMrecruited homeless substanceusers as participants. Althoughwe found little evidence for a dif-ferential effect on service utiliza-tion, the ndings provided someevidence that SCM is effective for this homeless subpopulation inimproving housing stability, reduc-ing substance use problems, andremoving employment barriers.For the mentally ill sample, how-ever, few of these results werereplicated. Thus, SCM seemed to be more bene cial than usual carefor substance-using homeless persons.

Five out of 7 studies that assessed the effect of ICM also

focused on homeless substanceusers. For this group, ndingswere nonsigni cant or mixed inall outcome categories except for

access to public assistance. Studyquality ratings and service utiliza-tion data suggested that theselargely nonsigni cant ndingscould be the result of treatment nonadherence and lack of between-group differentiationin the services received. The 2other ICM studies provided someevidence for a positive effect of ICM on housing outcomes for severely mentally ill homeless persons and the general home-less population. However, moreresearch is needed before anyconclusions can be drawn about the consistency of these ndings.

The samples in studies of ACT consisted of homeless persons with dual diagnoses,severely mentally ill persons,substance-using veterans, andmentally ill ex-prisoners. Resultsindicated that ACT improved the housing stability of severely men-

tally ill as well as dually diagnosed homeless participants more thanless proactive case management models. Outcomes related to hous-ing were not included in the studywith mentally ill ex-prisoners anddid not improve in the sample of substance-using veterans;however,this could be attributable toa lack of model delity in thisstudy. For all subpopulations,

ndings in the other outcomecategories were largely nonsig-ni cant or inconsistent. Al-though ACT appeared to in u-ence patterns of mental healthservice use, most studies did not show a differential effect of ACT on psychopathology or other mental health outcomes.Nevertheless, the improvementsin housing stability and reduc-tions in inpatient and emergencymental health service use seemed

SYSTEMATIC REVIEW



12/15

to be suf cient to compensate for the higher costs associated withACT.

Our ndings are consistent

with the 4 previous reviews of the literature on this topic. Allthese reviews found ACT supe-rior to other services, including other models of case manage-ment, in helping severely men-tally ill homeless persons toachieve housing stability.19,25---27

Contrary to our ndings, however,Coldwell and Bender also con-cluded that ACT participantsdemonstrated greater improve-ment in psychiatric symptomseverity. 26

CTI was examined in 2 samples of severely mental ly ill homeless persons, 1 group leav-ing a homeless shelter and theother leaving inpatient care for veterans. For both groups, CTIwas signi cantly better thanusual services in supporting housing stabili ty and reducing psychiatric symptoms and sub-stance use. The improved level of

housing stabil ity experienced bythese severely mentally ill partic-ipants appeared to be linked tothe positive impact of CTI on thelength of hospital, shelter, andother institutional stays. CTIachieved better long-term resultsthan usual care with similar as-sociated costs. CTI was the least researched model in our review,so consistent results from further studies are needed. Nevertheless,results from these 2 studies werevery promising.

Across the 4 different models,case management generallyseemed to have a positive impact on housing stability and patternsof service use. Findings about substance use outcomes weremixed, and effects on variablesmeasuring health, societal participation, and quality of life werelargely nonsigni cant.

LimitationsBecause of great variability be-

tween studies, comparisons of re-search ndings could only be un-

dertaken with great caution. Inaddition, caution was warranted by heavy reliance on participants

self-reports. Self-report data cangive rise to over- or underreport-ing of treatment effects and a dis-tortion of the differences betweenexperimental and controlgroups.72---74

We excluded reports that werenot published in English between1985 and 2011, possibly giving rise to selection bias. We alsoexcluded studies that did not in-clude a control group, such asdescriptive reports and studieswith a pretest---posttest design. Thequalitative information that wemay have omitted as a result might have elucidated the quantitativedata provided by randomizedand quasi-experimental research.

Generalizing ResearchFindings

Our review showed that casemanagement has produced favor-able effects in homeless popula-tions, but also revealed gaps in theevidence. Because the evidencefor the effectiveness of case man-agement has been collected in thecontext of speci c times, locations,and service settings, this researchcannot easily be extrapolated.Most of the trials in our review that assessed the effectiveness of case management were conductedin a particular time frame as part of multisite demonstration pro-grams in the United States that addressed the speci c problemsof homelessness of that time andfocused on individuals withchronic or severe mental illness,substance abuse problems, or dualdiagnoses.75,76 Although the prevalence of mental illness andsubstance use among homeless

people is still high, many are not mentally ill.11 More evidence isneeded to establish which modelis most suitable and cost-effective

for homeless people who are not mentally ill and are not substanceusers but who often have fewer or other support needs.

Similarly, we found examplesof limited generalizability acrosscountries. All but 1 of the studieswe reviewed were conducted inthe United States. The only Euro- pean study, from the UnitedKingdom, could not replicatemany of the ndings from earlier studies. Because other countries have marked differences in socialwelfare systems, housing and labor markets, and healthcare systems, inaddition to differences in the natureof their homeless populations, 10,77

it is highly likely that evidence- based practices from the UnitedStates will not produce the sameresults in European countries. Ina review of the research literaturesin the United States and other de-veloped nations, Toro also notes

that systematic research evaluating interventions for homeless peopleis virtually nonexistent in Europe. 10

Implications for FutureResearch and Practice

To properly inform policy-makers in the European Union,experimental trials should beconducted among different homeless groups in a variety of service settings and countries.These studies should be carefullydesigned. They should aim for more uniformity in outcomes ex-amined and for more standardi-zation of measurement instru-ments. Moreover, several important outcomes have received insuf -cient study. Few publications inour review included outcomesrelated to quality of life, societal participation, physical health, or community integration.

Future studies should summa-rize or refer to key componentsof the intervention being studiedand present results of model -

delity assessment.19,27

Inclusion of model delity in the study designis vital to explore relationships between case management models, homeless subgroups,service settings, and outcomes.Rather than comparing compet-ing models, it may be morefruitful to attempt to predict which well-de ned componentsof a given case management model will facilitate favorableoutcomes for certain homelesssubpopulations and what ap- proachwill be most cost-effective.78

Our results suggest that practi-tioners could employ case man-agement to assist homeless per-sons with improving their housing stability and changing their serviceuse patterns. We found little evi-dence for the effectiveness of ICM, but this could very well be attrib-utable to factors not related to thismodel. SCM seems to improve

housing stability, reduce substanceuse problems, and remove employment barriers for homelesssubstance users more than referralto community services. Comparedwith SCM and other case man-agement services, ACT has con-sistently produced positive effectson housing stability and has beenfound to be cost-effective. How-ever, this model seems to be suit-able mainly for mentally ill or dually diagnosed homeless per-sons with multiple and complex needs. 23 CTI has also produced promising results and seems to bemore applicable for a variety of settings and populations becauseof its practical and time-limitednature. 24 Only when the evidencegaps have been addressed can weestablish which case management models or which speci c compo-nents of these models are most

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suitable to accompany housing, as part of a rapid-rehousing approachto homelessness, for speci c home-less subgroups. j

About the Authors At the time of the study, Rene de Vet,Maurice J. A. van Luijtelaar, Sonja N.Brilleslijper-Kater, Marille D. Beijersbergen,and Judith R. L. M. Wolf were with the Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Netherlands. Sonja N.Brilleslijper-Kater is with the Child Abuse and Neglect Team, Academic Medical Center, Amsterdam, Netherlands. Wouter Vanderplasschen is with the Department of Orthopedagogics, Ghent University,Belgium.

Correspondence should be sent to Judith R. L. M. Wolf, PhD, Radboud University Nijmegen Medical Centre, Department of Primary and Community Care, PO Box 9101, 6500 HB Nijmegen, Netherlands (e-mail: [email protected]). Reprints can be orderedat http://www.ajph.org byclicking the Reprints link.

This article was accepted May 23,2013.

ContributorsR. de Vet led the writing and assistedwith the study. M. J. A. van Luijtelaar conducted the search and assistedwith the study and writing. S. N.

Brilleslijper-Kater assisted with the study. J. R. L. M. Wolf originated, designed, andsupervised the study and obtainedfunding, assisted by M.D. Beijersbergen.All authors conceptualized ideas,interpreted ndings, and reviewed draftsof the article.

AcknowledgmentsThis study was funded in part by theNetherlands Organization for Health Re-search and Development.

We thank the authors who assisted uswith obtaining full versions of publica-tions unavailable in the Netherlands. Wealso acknowledge the contribution of

Lenny Schouten, research assistant, De- partment of Primary and CommunityCare, Radboud University NijmegenMedical Centre, to the study selectionand data extraction process.

Note. The funding organization hadno role in the design and conduct of thestudy; in the collection, analysis, and in-terpretation of the data; or in the prepa-ration, review, or approval of the article.

Human Participant ProtectionNo protocol approval was required be-cause the data were obtained from sec-ondary sources.

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