Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial

Vicky Stergiopoulos,Kwame Mckenzie,Agnes Gozdzik,Anna Skosireva,Vachan Misir,Adam Whisler,Aseefa Sarang,Jo Connelly,Stephen W Hwang,Patricia O’Campo,Branko Aleksic

doi:10.1371/journal.pone.0130281

Abstract

Housing First (HF) is being widely disseminated in efforts to end homelessness among homeless adults with psychiatric disabilities. This study evaluates the effectiveness of HF with Intensive Case Management (ICM) among ethnically diverse homeless adults in an urban setting. 378 participants were randomized to HF with ICM or treatment-as-usual (TAU) in Toronto (Canada), and followed for 24 months. Measures of effectiveness included housing stability, physical (EQ5D-VAS) and mental (CSI, GAIN-SS) health, social functioning (MCAS), quality of life (QoLI20), and health service use. Two-thirds of the sample (63%) was from racialized groups and half (50%) were born outside Canada. Over the 24 months of follow-up, HF participants spent a significantly greater percentage of time in stable residences compared to TAU participants (75.1% 95% CI 70.5 to 79.7 vs. 39.3% 95% CI 34.3 to 44.2, respectively). Similarly, community functioning (MCAS) improved significantly from baseline in HF compared to TAU participants (change in mean difference = +1.67 95% CI 0.04 to 3.30). There was a significant reduction in the number of days spent experiencing alcohol problems among the HF compared to TAU participants at 24 months (ratio of rate ratios = 0.47 95% CI 0.22 to 0.99) relative to baseline, a reduction of 53%. Although the number of emergency department visits and days in hospital over 24 months did not differ significantly between HF and TAU participants, fewer HF participants compared to TAU participants had 1 or more hospitalizations during this period (70.4% vs. 81.1%, respectively; P=0.044). Compared to non-racialized HF participants, racialized HF participants saw an increase in the amount of money spent on alcohol (change in mean difference = $112.90 95% CI 5.84 to 219.96) and a reduction in physical community integration (ratio of rate ratios = 0.67 95% CI 0.47 to 0.96) from baseline to 24 months. Secondary analyses found a significant reduction in the number of days experiencing problems due to alcohol use among foreign-born (vs. Canadian-born) HF participants at 24 months (ratio of rate ratios = 0.19 95% 0.04 to 0.88), relative to baseline. Compared to usual care, HF with ICM can improve housing stability and community functioning and reduce the days of alcohol related problems in an ethnically diverse sample of homeless adults with mental illness within 2-years.Trial RegistrationControlled-Trials.com ISRCTN42520374.

Highlights

Homelessness is a significant social problem in Toronto, Canada’s largest and most ethnically diverse urban center, where approximately 29,000 individuals use shelters each year and roughly 5,000 people are homeless on any given night [1, 2].To address the pervasive problem of homelessness among individuals experiencing mental illness, in 2009, the Mental Health Commission of Canada (MHCC) launched the At Home/ Chez Soi (AH/CS) research demonstration project, a four-year multi-site randomized controlled trial of Housing First (HF) [3]
Employing the framework that policy needs to be informed by which programs work best, but what programs work best for whom and in what contexts [43], the goal of this paper is to evaluate the effectiveness of HF with Intensive Case Management (ICM) (HF-ICM) at 24 months post-randomization in an ethnically diverse sample of homeless individuals with mental illness who reside in a service-rich urban center
We examined the main effect of immigrant status on all outcome measures and found significant associations with severity of substance use problems (GAIN-SS; P

Summary

Introduction

Previous studies from the US have shown that the HF model can improve housing and other outcomes among homeless individuals with mental illness [5,6,7,8,9,10,11,12,13,14,15,16,17,18]; the AH/CS project is the first to evaluate the HF approach outside of the U.S service context and with both ACT and Intensive Case Management (ICM) levels of support. The Toronto site of the AH/CS project allows for the opportunity to evaluate the effectiveness of HF with ICM via a randomized controlled trial design in an ethnically diverse homeless population, who may experience additional barriers in accessing appropriate and timely housing and mental health care, within a system of universal access to health care [22,23,24,25]

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