Evidence-based health care management 0 Harcourt Brace amt Company Limited 1997

'Critical time' interventions reduced homelessness among mentally-ill men discharged from a psychiatry program in a men's shelter to community housing

Susser E, Valencia E, Conover S, Felix A, Wei-Yann Tsai, Wyatt R J. Preventing recurrent homelessness among mentally ill men: a 'critical time' hztervention after discharge from a sheRer. Am J Public Health 1997; 87:256-262

Objective

To evaluate the effectiveness of critical time interventions.

Setting

New York, NY, USA.

Method

Randomized-controlledtrial. 102 men who were discharged to housing in New York City region were invited to participate in a clinical trial; 96 men were randomly assigned to receive either critical time interventions (CTI) or usual services only (USO).

Critical time intervention has two main components. The first seeks to strengthen the individual's ties to services, family and friends; the second seeks to provide support, both emotional and practical, during the period of transition from a men's shelter with an intensive care program to community housing.

The men in the CTI group received 9 months of CTI plus usual services, and then usual services only for the following 9 months. The men in the control group re- ceived the usual services only for 18 months.

Literature review

No explicit strategy; 47 references, 11 of which were intervention studies to reduce the mental health problems and homeless- ness of people with severe mental illness.

Outcome measures

Mental health status was assessed using standardized and validated instruments.

Homelessness was assessed by the number of homeless nights during the follow-up period and the episodes of major homeless- ness lasting 30 nights or more.

Analysis

Data were analyzed on an hztention-to-treat basis (cases were included whether or not the

client actually completed a planned intervention).

Results

The average number of homeless nights over the 18-month follow-up period was 30 for the CTI group and 91 for the USO group, a statistically significant difference.

Authors' conclusions

The authors conclude that critical time intervention significantly reduced homelessness in a population with severe mental illness, with many of the men also being substance abusers and having serious health problems, including HIV infection.

Critical time intervention prevented 'most, though not all, of the recurrent homelessness.' In the last month of the study 8% of men in the CTI group and 23% of men in the control group were homeless.

The effect of critical time intervention increased after a 9-month period of active intervention and the effect was main-rained for 9 months after the intervention was withdrawn, perhaps because the explicit aim of CTI was not to provide primary care, but to build durable ties between patients and long-term support. The third main effect of CTI was that the CTI group had half the risk of extended homelessness.

Allowing for the limitations of the study, the authors conclude that they have identified an intervention which services could deliver within available resources by organizing and focusing care at a critical time in the career of a patient and by taking steps to prevent undue dependence on professional services.

Commentary The findings of this study should be of interest to those concerned with mental health services planning and evaluation because of the relevance of the issues that are examined and because of the implications of the reported outcomes.

There are a number of examples of attempts to systematize community-based care for mentally-ill people, the better- known being care management and, in the UK, the Care Programme Approach. Most of these are based on assumptions about good practice, but there is little evidence of their efficacy.

There is a growing body of evidence that these approaches are more effective jf they are targeted to those in need and if they take

the form of relatively limited assertive programs.

This study addresses homelessness in a group of vulnerable males with serious mental illness and suggests that assertive intervention at the time of transfer from one type of care to another lessens the risk of continuing homelessness. The study does not assume that homelessness is a proxy for morbidity and the authors promise additional data on the effects of the intervention program on clinical outcomes. The findings are, however, of interest because they are consistent with the view that targeted assertive interventions are more effective than routine or standard community care packages, and because they highlight the importance of relevant social and therapeutic

inputs at times of transition, which is when mentally-ill people are most vulnerable to relapse and there is an increased incidence of suicide attempts.

The specific components of the intervention program described in the study are of additional interest, but its value derives primarily from its reinforcement of the need for an increasing emphasis on timely, assertive and targeted community- based interventions rather than an emphasis of a 'routine care for all' model of community care.

Dr Michael Orr Chief Executive

Oxfordshire Mental Healthcare NHS Trust, Oxford, UK

98 EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT DECEMBER 1997