Effectiveness of Interventions to Improve the Health and Housing Status of Homeless People

A Rapid Systematic Review

Donna Fitzpatrick-Lewis; Rebecca Ganann; Shari Krishnaratne; Donna Ciliska; Fiona Kouyoumdjian; Stephen W Hwang

BMC Public Health. 2011;11(638)

Conclusions

Health and social policies that include the provision of housing as an intervention can be effective for improving health as well as housing status. Provision of housing should optimally be provided within an integrated model in which other supportive services are offered on site. Such integrated models appear to be most effective in achieving and sustaining long-term housing, as well as increasing utilization of health care services for chronically ill homeless populations. These services can range from case management to the provision of meals. There is some evidence that a relatively simple intervention such as rental assistance increases time housed.

For populations that are homeless or at risk of homelessness that have substance abuse issues, housing that was contingent on abstinence had better outcomes than when no housing was provided on several outcomes including drug abstinence and maintaining stable housing. While some benefit has been found related to abstinence-contingent housing versus no housing, housing that is not contingent on abstinence was found to be most effective for improving long term housing tenure, substance abstinence, or psychiatric outcomes.

Case management appears to be another effective intervention to improve health outcomes across various homeless populations. Case management has several positive effects including completion of courses of treatment and retention within community based treatment programs, reduced in-patient services, improved quality of life (including housing), and high client satisfaction. Case management appears to be most effective for homeless people when it is integrated, supportive, and well matched to clients.

Findings from this review are in good agreement with those from the 2005 review by Hwang and colleagues.^[6] Although new studies strong and moderate quality were limited, much of the new data in this review addresses gaps in the literature regarding the effectiveness of housing provisions interventions on the health and access to healthcare for people who are homeless or marginally housed. In addition, the new data identifies that these interventions can also be effective for improving an individual's housing status. Of significance is the new evidence for interventions that support people who have HIV and are homeless or at risk of homelessness. Notwithstanding, there remains a need for controlled studies in homeless persons with other infectious diseases, as well as studies examining sub-populations of homeless people that include women, families and children.

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Competing interests
The authors declare that they have no competing interests.

Authors' contributions
DFL conceived of the study, participated in the design of the study, title and abstract screening, full text screening, data extraction and analysis, and drafted the manuscript. RG participated in title and abstract screening, full text screening, and contributed to the manuscript drafts. SK carried out the grey literature search, participated in title and abstract screening, full text screening, and contributed to the manuscript drafts. DC conceived of the study, participated in the design of the study, title and abstract screening, full text screening, and contributed to the manuscript drafts. FK contributed to the conception of the study, participated in the study design, and contributed to the manuscript drafts. SH was the lead author on the original review, contributed to the conception of the study, participated in the study design, and contributed to the manuscript drafts. All authors read and approved the final manuscript.

Acknowledgements
Partial funding for this paper was provided to the Effective Public Health Practice Project by the Region of Peel, Canada. In 2009 the Region of Peel commissioned the Effective Public Health Practice Project, McMaster University, Hamilton Ontario a review entitled "Interventions to increase access to health and health care, including housing, for people who are homeless or at risk of homelessness: Expedited review". (To access this review contact Joan Davison at joan.davison@peelregion.ca). This current review contains some overlap of retrieved articles and methodological ratings with those found for the Region of Peel review, however, the search was redone and the inclusion criteria were different for this update.

Cite this: Effectiveness of Interventions to Improve the Health and Housing Status of Homeless People - Medscape - Aug 10, 2011.

Table 1. Quality Assessment Results for Methodologically Moderate Relevant Studies (n = 10)
Author/Date	Selection Bias	Study Design	Confounders	Blinding	Data Collection Methods	Withdrawals/Dropouts	Global Rating
Forchuk, Maclure, Van Beers, Smith, Csiernik, Hoch et al., 2008 [82]	Weak	Strong	Strong	Moderate	Strong	Strong	Moderate
Kushel, Colfax, Ragland, Heineman, Palacio, & Bangsberg, 2006 [101]	Moderate	Moderate	Strong	Weak	Strong	Strong	Moderate
Larimer, Malone, Garner, Atkins, Burlingham, Lonczak et al., 2009 [83]	Moderate	Moderate	Strong	Weak	Strong	Moderate	Moderate
Milby, Schumacher, McNamara, Wallace, Usdan, McGill et al., 2004 Milby, Schumacher, Wallace, Frison, McNamara, Usdan et al., 2003 Milby, Schumacher, Vuchinich, Wallace, Plant, Freedman et al., 2004 [84–86]	Moderate	Strong	Strong	Moderate	Strong	Moderate	Moderate
Milby, Schumacher, Wallace, Freedman & Vuchinich, 2005 Kertesz, Mullins, Schumacher, Wallace, Kirk & Milby, 2007 [87,88]	Moderate	Strong	Strong	Moderate	Strong	Weak	Moderate
Rotheram-Borus, Desmond, Comulada, Arnold, & Johnson, 2009 [97]	Moderate	Strong	Strong	Moderate	Strong	Moderate	Moderate
Schwarcz, Hsu, Vittinghoff, Vu, Bamberger, & Katz, 2009 [98]	Strong	Moderate	Strong	Strong	Weak	Not Applicable	Moderate
Slesnick, Prestopnik, Meyers, & Glassman, 2008 Slesnick & Kang, 2008 [102,103]	Moderate	Strong	Strong	Weak	Strong	Moderate	Moderate
Tsemberis, Moran, Shinn, Armussen, & Shern, 2003 Padgett, Gulcur, & Tsemberis, 2006 Tsemberis, Gulcur, & Nakae, 2004 Gulcur, Tsemberis, Stefancic, & Greenwood, 2007 Greenwood, Schaefer-McDaniel, Winkel, & Tsemberis, 2005 Stefancic, Schaefer-McDaniel, Davis, & Tsemberis, 2004 [90–92,120–122]	Moderate	Strong	Strong	Weak	Strong	Strong	Moderate
Wolitski, Kidder & Fenton, 2007 Kidder, Wolitski, Royal, Aidala, Courtenary-Quirk, Holtgrave et al., 2007 [123,124]	Moderate	Strong	Strong	Weak	Strong	Strong	Moderate

Table 2. Summary of Evidence Table: Interventions for Homeless People
Study	Outcomes
Interventions for Homeless People with Mental Illness
Forchuk et al., 2008 [82]
Study design: Randomized controlled trial (RCT) Sample size: 14 Study population: Patients being discharged from psychiatric wards to shelters and 'no fixed address'. Approach: This pilot study examined the effectiveness of an intervention in preventing homelessness upon discharge from a psychiatric admission.	All the individuals in the intervention group maintained housed status at 3 and 6 months following hospital discharge. All but one participant in the control group remained homeless after 3 and 6 months (p < .001)
Interventions for Homeless People with Substance Abuse
Larimer et al., 2009 [83]
Study design: Quasi-experimental with four data points (baseline, 3, 6 and 12 months) Sample size: 134 Study population: Study reports drawing from a 'chronically homeless' list of individuals with high local crisis services utilization patterns. Chronic homelessness is not further defined. Approach: This study evaluated the association of a Housing First intervention for chronically homeless individuals with severe alcohol problems with health care use and costs.	Median number of drinks dropped from 15.7 per day prior to housing to 14.0, 12.5, and 10.6 per day at 6, 9, and 12 months in housing respectively. Poisson GEE with a linear time covariate showed a similar trend to the medians, with an approximately 2% decrease per month in daily drinking while participants were housed (RR, 0.98; 95% CI, 0.96–0.99).
Milby et al., 2004; Milby et al., 2003; Milby et al., 2000 [14–16]
Study design: RCT Sample size: 110 (Milby et al., 2000); 141 (Milby et al., 2003; 2004) Study population: Homeless population defined as lacking a fixed overnight residence, including shelters or temporary accommodations, or were at immediate risk of being homeless. Approach: This study the effectiveness of behavioural day treatment plus abstinence-contingent housing and work therapy (DT+) versus behavioural day treatment (DT) alone on abstinence and housing outcomes.	Percentages of days abstinent over proceeding 60 days at 2 months were for DT 41% versus DT+ 71%, and at 6 months were for DT 15% versus DT+ 41%. Of the 117 participants who established complete or partial abstinence, lapse (i.e., drug use during 1 week or less) was lower in the DT group than the DT+ group (45% vs 61%). Relapse (i.e., drug use in at least 2 consecutive weeks over the 24-weeek period), however, was considerably higher with DT compared to DT+ treatment (81% vs 55%). The only significant difference in percentage days housed between DT and DT+ was at the 6-month point. The number of mean days housed in the past 60 days increased in both groups.
Milby et al., 2005; Kertesz et al., 2007 [17,18]
Study design: RCT Sample size: 196 Study population: Homeless population defined as lacking a fixed overnight residence, including shelters or temporary accommodations, or were at immediate risk of being homeless. Approach: This RCT examined how substance abuse treatment outcomes were affected under 3 different housing provision conditions (N = 195).	There was evidence of an overall housing group effect and an effect of attendance on abstinence. The mean adjusted consecutive weeks of abstinence for the 'No Housing' (NH), 'non-abstinence-contingent housing' (NACH) and abstinence-contingent housing (ACH) groups were 5.28, 4.68, and 7.32, with a significant difference between the ACH group and the NH group and between the ACH group and the NACH groups, but no difference between the NACH group and the NH group. There were significant within-group housing changes from baseline to 12 months for all groups and for each group.
Gulcur et al., 2003; Tsemberis et al., 2004; Tsemberis et al., 2003; Padgett et al., 2006; Greenwood et al., 2005; Stefancic et al., 2004 [20–22,52–54]
Study design: RCT Sample size: 225 Study population: Met the following criteria for homelessness: spent 15 out of the last 30 days on the street (not including shelters) and experienced period of 'housing instability' (not defined) within last six months. Approach: This set of papers reported on an RCT that examined two approaches to housing chronically homeless individuals with psychiatric disabilities and substance abuse (Pathways First; Continuum of Care) (N = 225).	Housing First increased housing tenure and reduced hospitalization. This successful program offers housing first and has a focus on client choice. *Proportion of time homeless:* At the end of 6 months after baseline 79% of the experimental group were living in stable housing compared to 27% in the control group. *Proportion of time hospitalized:* The control group spent significantly more time in hospitals than the experimental group. *Substance use:* There were no differences in either alcohol or drug use between the 2 groups. *Substance use treatment utilization:* The control group reported higher use of substance abuse treatment programs than the Housing First group. A decrease in service use occurred in the Housing First group and an increase occurred in the control group over time. *Psychiatric symptoms:* No significant differences in psychiatric symptoms between groups.
Interventions for Homeless People with HIV
Kushel et al., 2006 [101]
Study design: Prospective observational cohort Sample size: 280 Study population: HIV+ homeless and marginally housed individuals. Homeless was defined as ≥ one night on street or in shelter in last quarter, whereas marginally housed was defined as ≥ 90% of nights in single-room occupancy dwelling in past quarter with no nights spent on street or in shelter. Approach: This study examined the effect of case management on acute health services use and health outcomes in homeless or marginally housed persons with HIV.	Health services utilization: Moderate CM was associated with increased adherence to antiretroviral therapy compared to no or rare CM. CM was not associated with increased use of primary care or hospital-based services. Health/biological: Both consistent and moderate CM were associated with ≥ 50% improvements in CD4+ cell count.
Rotheram-Borus et al., 2009 [97]
Study design: RCT, sub-group analysis Sample size: 270 Study population: HIV+ marginally housed individuals including reports of currently being homeless, living in a shelter or welfare hotel, or having lived in either condition within the 12 months prior to each assessment. Approach: The subgroup analysis (N = 270) of participants in a larger RCT (N = 936) examined the efficacy of the Healthy Living Program in reducing sexual behaviour and substance use among adults with HIV who were marginally housed. The intervention might have worked by inducing abstinence from targeted behaviours or by reducing frequency of acts.	Risk behaviours: no statistically significant differences in intervention effects (P values ranged from .072 days using alcohol or marijuana to .275 for number of partners who were HIV-negative or of unknown serostatus). Most significant effects were the numbers of partners who were HIV-negative or of unknown serostatus and the number of days of alcohol or marijuana use. The intervention also reduced the number of risky sexual acts and the number of days of hard drug use compared to the control.
Schwarcz et al., 2009 [98]
Study design: Retrospective observational study Sample size: 6,558 Study population: HIV+ individuals. Cases were defined as homeless if medical records documented individuals were homeless or if addresses listed in chart were for shelters, health care clinics, or a general delivery address not connected to an address. Approach: This study examined the effect of homeless on the mortality of persons with AIDS and the effect of supportive housing on AIDS survival.	After adjusting for confounders, homelessness was significantly associated with increased mortality (RH 1.20; 95% CL 1.03, 1.41). Receiving housing post diagnosis improved survival rates (adjusted RH 0.20; 95% CL 0.05, 0.81).
Slesnick et al., 2007; Slesnick & Kang, 2008 [33,34]
Study design: RCT Sample size: 172 Study population: Homeless youth, with homelessness defined as having no place of shelter and is in need of services and shelter where supervision and care are provided. Approach: This RCT (N = 180) evaluated change in HIV risk behaviours among a sample of homeless youth.	Youth who received the Community Reinforcement Approach therapy + HIV education reported better improvement on the frequency of condom use than the control treatment as usual group. Youth in the intervention group showed a greater decrease in substance free days than in the control group.
Woliski et al., 2009; Kidder et al., 2007 [55,56]
Study design: RCT Sample size: 644 Study population: HIV+ individuals living in the following housing contexts: having one's own place to live, being unstably housed (staying temporarily with others/living in a transitional setting and had not been homeless), or being homeless ≥ one night (e.g., sleeping in shelters or locations not suitable for human habitation) in the last 90 days. Approach: This study evaluated the effectiveness of providing rental assistance to homeless people living with HIV/AIDS on physical health, access to medical care, treatment adherence, HIV risk behaviours, and mental health status.	At 18 months, 51% of the comparison group had housing. Intent-to-treat analysis indicated significant improvements in self-reported physical and mental health. Significant improvements between stably housed versus homeless participants were found in as-treated analysis for health care utilization, perceived stress and detectable viral load.

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Effectiveness of Interventions to Improve the Health and Housing Status of Homeless People

A Rapid Systematic Review

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