Abstract
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. 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. 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.
Highlights
Homeless and vulnerably housed populations have poorer health outcomes including acute and chronic illness [1], traumatic injury [1], mental health and substance use disorders [2,3,4,5,6,7], and mortality [8]
Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study
While case management interventions are heterogeneous in definition, complexity, target populations served, and modes of delivery [12], among these, four predominant models have evolved in relation to health care: standard case management (SCM), intensive case management (ICM), assertive community treatment (ACT), and critical time intervention (CTI) (See Table 1) [17]
Summary
Homeless and vulnerably housed populations have poorer health outcomes including acute and chronic illness [1], traumatic injury [1], mental health and substance use disorders [2,3,4,5,6,7], and mortality [8]. While often related to individual medical and complex social needs, structural challenges posed by fragmented health and social systems create a potent mix of barriers to access to health care These include a lack of sufficient language capacity, awareness of affordable healthcare services and their location, transportation services, childcare, and reasonable wait times. When coupled with previous experiences of rejection or discrimination from service providers, these barriers further contribute to individuals failing to access appropriate and available health care [9,10,11] To address these barriers, people who are homeless or vulnerably housed may benefit from tailored, patient-centered care with an integrated approach to community and social services [12,13,14]. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations
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