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

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 registration: Controlled-Trials.com ISRCTN42520374.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Participant flow through the study.

Fig 2. Primary study outcome, by treatment group and ethnicity.

Values correspond to adjusted means and bars correspond to standard errors from linear regression model (using a mixed effect model framework) for the percentage of days stably housed over 24 month follow-up period for HF-ICM and TAU groups among participants, by ethnicity.

Fig 3. Select secondary outcomes, mean (95% CI), by treatment group over time.

Solid and dashed lines indicate the HF-ICM and TAU groups, respectively.

Fig 4. Mean (95% CI) amount spent on alcohol, by treatment group and ethnicity over time.

Solid and dashed lines indicate the HF-ICM and TAU groups, respectively. Among racialized participants, HF-ICM participants decreased spending from $32.30 at baseline to $30.32 at 24 months, while TAU participants increased spending from $36.50 to $44.29 from baseline to 24 months, respectively. Among non-racialized participants, HF-ICM participants decreased spending from $91.69 at baseline to $66.73 at 24 months, while their TAU counterparts increased from $105.91 to $203.63 from baseline to 24-months, respectively. All values are in $CAD.