A program that included scattered-site supportive housing using rent supplements and case management services led to more stable housing for homeless adults with mental illness in four cities in Canada, compared with usual access to existing housing and community services, but the intervention did not result in significant improvements in health-related quality of life, according to a study in the March 3 issue of JAMA.
Homelessness affects large numbers of people in many countries and is associated with enormous personal and societal costs. One-year prevalence estimates indicate there were at least 150,000 homeless people in Canada in 2009 and 1.5 million in the United States in 2012. Large numbers of homeless adults have mental illness, with or without substance use disorders. Although the intervention Assertive Community Treatment (ACT) provides support via a resource-intensive interdisciplinary team (including a psychiatrist and nurses) and small caseloads, Intensive Case Management (ICM) is a less-intensive intervention in which individual case managers broker necessary services to other supports in the community. Intensive Case Management may be an appropriate and less-costly treatment option for homeless individuals not requiring ACT service intensity, according to background information in the article.
Vicky Stergiopoulos, M.D., and Stephen W. Hwang, M.D., of St. Michael's Hospital, Toronto, and colleagues conducted a study in which 1,198 homeless adults with mental illnesses (recruited in Vancouver, Winnipeg, Toronto, and Montreal) were randomly assigned to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months. The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities.
The researchers found that during the 24 months following randomization, the percentage of days stably housed was higher among the intervention group than the usual care group: Site A, 63 percent vs 30 percent; Site B, 73 percent vs 24 percent; Site C, 74 percent vs 39 percent; and Site D, 77 percent vs 32 percent.
On a measure of quality of life, assessed by a health questionnaire, the average change of the score from baseline to 24 months was not statistically different between intervention or usual care participants. Additional analyses suggested significant gains in condition-specific quality of life among the intervention group compared with the usual care group, such as for measures of living situation and safety.
"Our findings highlight that scattered-site housing with ICM services is effective in reducing homelessness among a broader spectrum of the homeless population who may have a severe mental illness but do not require ACT support, best reserved for a smaller group of homeless adults with high needs for mental health and other support services," the authors write.
Editorial: Housing as a Remedy for Chronic Homelessness
Mitchell H. Katz, M.D., of the County of Los Angeles, Department of Health Services, Los Angeles, comments on this topic in an accompanying editorial.
"Clinicians who provide care for homeless persons are aware that they can order a variety of reimbursable tests and treatments for them, except the one intervention that most likely would make all the difference -- supportive housing. There are many conditions medicine cannot cure; chronic homelessness does not need to be one of them."
"More than half a million persons are homeless in the United States on a given night. The study by Stergiopoulos et al suggests that there is a solution to what has been a difficult and emotionally distressing problem in the United States, Canada, and around the world."
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