Supporting Vulnerable People During Challenging Transitions: A Systematic Review of Critical Time Intervention.

Critical Time Intervention (CTI) is designed to reduce the risk of homelessness and other adverse outcomes by providing support to individuals during challenging life course transitions. While several narrative reviews suggest the benefit of CTI, the evidence on the model's effectiveness has not been systematically reviewed. This article systematically reviews studies of CTI applied to a variety of populations and transition types. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis for protocols (PRISMA-P) guidelines, we reviewed 13 eligible experimental and quasi-experimental studies. Findings were summarized by individual outcome domains, including housing, service engagement use, hospitalization or emergency services, mental health, substance use, family and social support, and quality of life. CTI had a consistent positive impact on two primary outcomes-reduced homelessness and increased service engagement use-among different populations and contexts. Despite the effectiveness of CTI, the specific mechanisms of the model's positive impacts remain unclear. Implications for practice, policy and research are addressed.

Fidelity Assessment of a Social Work-Led Intervention Among Patients with Firearm Injuries.

PURPOSE: To support future development and refinement of social work-led intervention programs among patients with firearm injuries and to demonstrate how a fidelity assessment can be used to adjust and refine intervention delivery in an ongoing trial. METHODS: We conducted a fidelity assessment of a randomized controlled trial of a social work-led intervention among patients with a firearm injury. RESULTS: We found that our study intervention was well implemented, meeting 70% of the fidelity assessment score items, however noted lower fidelity with client-based items. DISCUSSION: As a result of fidelity assessment findings, we refined intervention delivery to improve implementation fidelity including beginning to review cases of all patients each month, rather than focusing on patients in crisis. Our fidelity assessment process and findings offer insight into the challenges of implementing an intervention among patients with firearm injuries and highlights the value of monitoring intervention fidelity during an ongoing trial.

Critical Time Intervention for Homeless People Making the Transition to Community Living: A Randomized Controlled Trial.

To help create an evidence base in Europe for effective interventions that improve the well-being of homeless people, we tested whether critical time intervention (CTI), a time-limited intervention developed to support vulnerable people during times of transition, is effective outside the United States. For this multicenter, parallel-group randomized controlled trial, 183 adults who were moving from shelters in the Netherlands to supported or independent housing were allocated to CTI or care-as-usual. The primary outcome was number of days rehoused, which was assessed by interviewing participants four times during a 9-month follow-up. Outcomes were analyzed with three-level mixed-effects models. The primary outcome did not differ between groups. CTI had a significant effect on family support and, for people experiencing less social support, psychological distress. Groups did not differ significantly on social support, fulfillment of care needs, quality of life, self-esteem, excessive alcohol use, or cannabis use. Because few participants were homeless at 9 months, more research is needed to establish whether CTI can prevent long-term recurrent homelessness. Given recent emphasis on informal support in public services and positive effects of CTI on family support and psychological distress, CTI is a fitting intervention for Dutch shelter services.

Critical Time Intervention for People Leaving Shelters in the Netherlands: Assessing Fidelity and Exploring Facilitators and Barriers.

International dissemination of evidence-based interventions calls for rigorous evaluation. As part of an evaluation of critical time intervention (CTI) for homeless people and abused women leaving Dutch shelters, this study assessed fidelity in two service delivery systems and explored factors influencing model adherence. Data collection entailed chart review (n = 70) and two focus groups with CTI workers (n = 11). The intervention obtained an overall score of three out of five (fairly implemented) for compliance fidelity and chart quality combined. Fidelity did not differ significantly between service systems, supporting its suitability for a range of populations. The eight themes that emerged from the focus groups as affecting model adherence provide guidance for future implementation efforts.

The role of a critical time intervention on the experience of continuity of care among persons with severe mental illness after hospital discharge.

We investigated the impact of critical time intervention (CTI) on self-reported indicators of quality of continuity of care (COC) after discharge from inpatient psychiatric treatment with data from a randomized controlled trial that assessed the effectiveness of the intervention in reducing recurrent homelessness. Postdischarge COC outcome measures among previously homeless persons with severe mental illness randomly assigned to receive usual services only (n = 73) or 9 months of CTI in addition to usual services (n = 77) were compared. Those assigned to CTI had greater perceived access to care than the usual services group did, with this impact extending beyond the point at which the intervention ended. A time-limited care coordination intervention provided immediately after hospital discharge may improve COC, but further studies are needed to substantiate an effect of CTI on long-term continuity outcomes.

The effectiveness of critical time intervention for abused women and homeless people leaving Dutch shelters: study protocol of two randomised controlled trials.

BACKGROUND: One of the main priorities of Dutch organisations providing shelter services is to develop evidence-based interventions in the care for abused women and homeless people. To date, most of these organisations have not used specific intervention models and the interventions which have been implemented rarely have an empirical and theoretical foundation. The present studies aim to examine the effectiveness of critical time intervention (CTI) for abused women and homeless people. METHODS: In two multi-centre randomised controlled trials we investigate whether CTI, a time-limited (nine month) outreach intervention, is more effective than care-as-usual for abused women and homeless people making the transition from shelter facilities to supported or independent housing. Participants were recruited in 19 women's shelter facilities and 22 homeless shelter facilities across The Netherlands and randomly allocated to the intervention group (CTI) or the control group (care-as-usual). They were interviewed four times in nine months: once before leaving the shelter, and then at three, six and nine months after leaving the shelter. Quality of life (primary outcome for abused women) and recurrent loss of housing (primary outcome for homeless people) as well as secondary outcomes (e.g. care needs, self-esteem, loneliness, social support, substance use, psychological distress and service use) were assessed during the interviews. In addition, the model integrity of CTI was investigated during the data collection period. DISCUSSION: Based on international research CTI is expected to be an appropriate intervention for clients making the transition from institutional to community living. If CTI proves to be effective for abused women and homeless people, shelter services could include this case management model in their professional standards and improve the (quality of) services for clients. TRIAL REGISTRATION: NTR3463 and NTR3425.

"I hope I can make it out there": perceptions of women with severe mental illness on the transition from hospital to community.

This study explores the experience of women with severe mental illness in transition from psychiatric hospital care to the community. Three focus groups were conducted among women with severe mental illness from transitional residences at two state psychiatric hospitals. Focus group transcripts and notes were coded according to women's perceived challenges and facilitators of transition. Participants described several challenges including fear of insufficient treatment support, safety concerns, social isolation, stigma, and lack of resources to meet daily needs. The supports that women described as important were an orientation to the neighborhood and residence, access to treatment support with flexibility, and connection to social supports.

Discharge practices in a time-unlimited intervention: the perspectives of practitioners in assertive community treatment.

The Assertive Community Treatment (ACT) model for people with severe mental illness has typically been viewed as a time-unlimited intervention. Without a proscribed service duration, discharge from ACT largely depends on individual clients' situations and practitioners' discretion. We conducted semi-structured focus groups and interviews with practitioners to explore their discharge practices and considerations. Results highlight the heterogeneity of the clientele served in ACT, and therefore the importance of individualized treatment and discharge planning, guidance on assessing the timing of discharge for individual cases, practice strategies that balance independence and social connectedness to promote recovery, and the need for substantial system reform to facilitate transition after discharge.

Differences between homeless women and men before and after the transition from shelter to community living: A longitudinal analysis.

Social quality is the extent to which people are able to participate in social relationships under conditions which enhance their well-being, capacities and potential and enables them to shape their own circumstances and contribute to societal development. We assessed whether women in homeless shelters differed from men on social quality factors that constitute the quality of their daily life and whether factor scores changed at a different rate for women and men after shelter exit. Data were collected as part of a randomised controlled trial. In 18 shelters across the Netherlands, 183 participants were recruited between December 2010 and December 2012 and followed for 9 months. Adults were eligible if they were about to move from shelter to (supported) independent housing and their shelter stay had been shorter than 14 months. At baseline, women were significantly younger than men. They were more likely to have children, to have minor children staying with them, to be lower educated, to be unemployed and to have been victimised than men. Women had used more services and reported lower self-esteem, less satisfaction with health and empowerment and higher psychological distress. They were less likely than men to have used alcohol excessively or cannabis. We found no significant differences between women and men in changes over time on the social quality factors. As women were disadvantaged at baseline compared to men regarding many factors, we concluded that women in homeless shelters are a particularly vulnerable group. Moreover, an opportunity remains for shelter services to improve women's social quality during and after their shelter stay.

The effectiveness of critical time intervention for abused women leaving women's shelters: a randomized controlled trial.

OBJECTIVES: To examine the effectiveness of critical time intervention (CTI)-an evidence-based intervention-for abused women transitioning from women's shelters to community living. METHODS: A randomized controlled trial was conducted in nine women's shelters across the Netherlands. 136 women were assigned to CTI (n = 70) or care-as-usual (n = 66). Data were analyzed using intention-to-treat three-level mixed-effects models. RESULTS: Women in the CTI group had significant fewer symptoms of post-traumatic stress (secondary outcome) (adjusted mean difference - 7.27, 95% CI - 14.31 to - 0.22) and a significant fourfold reduction in unmet care needs (intermediate outcome) (95% CI 0.06-0.94) compared to women in the care-as-usual group. No differences were found for quality of life (primary outcome), re-abuse, symptoms of depression, psychological distress, self-esteem (secondary outcomes), family support, and social support (intermediate outcomes). CONCLUSIONS: This study shows that CTI is effective in a population of abused women in terms of a reduction of post-traumatic stress symptoms and unmet care needs. Because follow-up ended after the prescribed intervention period, further research is needed to determine the full long-term effects of CTI in this population.

Critical time intervention for reentry from prison for persons with mental illness.

Critical time intervention (CTI) is a nine-month, three-stage intervention that strategically develops individualized linkages in the community and seeks to enhance engagement with treatment and community supports through building problem-solving skills, motivational coaching, and advocacy with community agencies. It is an empirically supported practice shown to enhance continuity of care for people with mental illness after discharge from homeless shelters and psychiatric hospitals. This article describes CTI as a promising model to provide support for reentry from prison for people with mental illness. A conceptual model is presented for evaluating the impact of CTI on the transition from correctional settings to the community. The model is potentially useful for further development of mental health service-driven models of reentry process and outcome. Although CTI is a potentially useful model for reentry services for this population, challenges remain in adapting it to specific correctional facilities, justice systems, and community contexts.

Barriers and facilitators to successful transition from long-term residential substance abuse treatment.

Although residential substance abuse treatment has been shown to improve substance use and other outcomes, relapse is common. This qualitative study explores factors that hinder and help individuals during the transition from long-term residential substance abuse treatment to the community. Semi-structured interviews were conducted with 32 individuals from residential substance abuse treatment. Based on the socio-ecological model, barriers and facilitators to transition were identified across five levels: individual, interpersonal, organizational, community, and policy. The major results indicate that primary areas of intervention needed to improve outcomes for these high-risk individuals include access to stable housing and employment, aftercare services and positive support networks; expanded discharge planning services and transitional assistance; and funding to address gaps in service delivery and to meet individuals' basic needs. This study contributes to the literature by identifying transition barriers and facilitators from the perspectives of individuals in residential treatment, and by using the socio-ecological model to understand the complexity of this transition at multiple levels. Findings identify potential targets for enhanced support post-discharge from residential treatment.

Use of Peer Staff in a Critical Time Intervention for Frequent Users of a Psychiatric Emergency Room.

Project Connect, a clinical demonstration program developed in consultation with the New York State Office of Mental Health, adapted critical time intervention for frequent users of a large urban psychiatric emergency room (ER). Peer staff provided frequent users with time-limited care coordination. Participants increased their use of outpatient services over 12 months, compared with a similar group not enrolled in the program. For persons with significant general medical, psychiatric, and social needs, provision of this intervention alone is unlikely to reduce reliance on ERs, especially among homeless individuals.

Online Versus Face-To-Face Training of Critical Time Intervention: A Matching Cluster Randomized Trial.

This study examined the effectiveness of online education to providers who serve people experiencing homelessness, comparing online and face-to-face training of Critical Time Intervention (CTI), an evidence-based case management model. The authors recruited 184 staff from 19 homeless service agencies to participate in one of two training conditions: (a) Online Training + Community of Practice or (b) Face-to-Face Training + Telephone Consultation. Each group received 24 hours of instruction and support. Through baseline, follow-up, and nine-month post-training surveys, the authors examined satisfaction, knowledge gains, knowledge retention, and readiness to implement CTI. While satisfaction rates were higher among participants in the face-to-face group, the two training conditions produced comparable pre/post knowledge gains. Furthermore, both groups showed increased knowledge retention scores at nine-month follow up, with the online group scoring higher than the face-to-face group.

Mediation analysis of critical time intervention for persons living with serious mental illnesses: assessing the role of family relations in reducing psychiatric rehospitalization.

OBJECTIVE: Critical Time Intervention (CTI) is a time-limited care coordination intervention designed to reduce homelessness and other adverse outcomes for persons living with serious mental illness during the transition period between institutions and community living. This study assesses whether CTI improves the quality of family relationships between family members and individuals living with serious mental illness, and examines whether changes in quality of family relationship mediated the association between the intervention and psychiatric rehospitalization outcomes. METHOD: This study utilizes data from a randomized controlled trial that assessed the effect of CTI in preventing homelessness. Following discharge from inpatient psychiatric treatment in New York City, 150 previously homeless persons living with serious mental illness were randomly assigned to receive usual services only or 9 months of CTI in addition to usual services. RESULTS: Findings from mixed-effects regression models indicated that those assigned to the CTI group reported greater frequency of family contact and greater improvement in satisfaction with family relations than the comparison group during the 18-month follow-up period. Mediation analysis revealed that greater improvement in satisfaction with family relations mediated the effect of CTI on psychiatric rehospitalization outcome, but only at a modest level. CONCLUSION AND IMPLICATIONS FOR PRACTICE: These findings suggest that a relatively brief but targeted intervention delivered at the point of hospital discharge may contribute to strengthening family relations and that improvement in perceived family relationship quality can contribute to a reduction in psychiatric rehospitalization.

Public-academic partnerships: a rapid small-grant program for policy-relevant research: motivating public-academic partnerships.

To help grow a cadre of researchers with the knowledge and skills to pursue topics of great utility to public mental health systems, the director of the Division of Mental Health Services and Policy Research at Columbia University used funding from the New York State Office of Mental Health (OMH) to create a rapid small-grant program called the OMH Policy Scholars Program. This column uses two case examples to describe how this public-academic partnership exposes early-career researchers to the needs and complexities of large public mental health systems while providing them with senior research and policy mentors to help ensure the success of the scholars' projects and oversee their introduction to and work within the public mental health system. This type of collaboration is one model of encouraging early-career psychiatric researchers to pursue policy-relevant research.

The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge.

OBJECTIVES: This study examined the impact of critical time intervention (CTI) in reducing rehospitalization among formerly homeless individuals with severe and persistent mental illness after discharge from inpatient psychiatric treatment. METHODS: CTI is a nine-month care coordination intervention designed to support persons with severe mental illness in the transition from institutions to community living. After discharge from inpatient psychiatric treatment, 150 previously homeless men and women were randomly assigned to receive either usual services only or CTI in addition to usual services. Study participants were assessed every six weeks for 18 months after entering the community. RESULTS: At the end of the follow-up period, psychiatric rehospitalization was significantly lower for the group assigned to CTI compared with the usual services group (odds ratio=.11, 95% confidence interval=.01-.96). CONCLUSIONS: This study demonstrated that CTI, primarily designed to prevent recurrent homelessness, also reduced the occurrence of rehospitalization after discharge.

Community integration of formerly homeless men and women with severe mental illness after hospital discharge.

OBJECTIVE: This exploratory study examined the impact of critical time intervention (CTI), a time-limited care coordination model, on community integration among formerly homeless adults with severe mental illness after discharge from inpatient psychiatric treatment. METHODS: Data were from a randomized trial that enrolled 150 participants, 95 of whom completed 18-month outcome measures. Relationships between two components of community integration (social and physical) and demographic characteristics, symptom ratings, housing status, and treatment condition were examined. RESULTS: Neither assignment to CTI nor housing stability was associated with integration outcomes. General and negative symptoms were inversely associated with both physical and social integration. CONCLUSIONS: Although CTI and similar community support models may improve housing stability and reduce rehospitalization, they may not, by themselves, improve community integration. Future studies should focus on improving measurement of community integration so that it can be effectively studied as an important outcome of mental health interventions for this population.

Development and use of a transition readiness scale to help manage ACT team capacity.

OBJECTIVE: This article describes the creation, validation, and use of an assertive community treatment (ACT) Transition Readiness Scale (TRS) to identify clients who may be ready to transition from ACT services. Scale development was prompted by concerns over long stays on ACT teams and the resulting impact on access. METHODS: Data were extracted from a centralized clinical reporting system for all 1,365 persons enrolled for at least 12 months as of August 2008 in the 42 ACT teams in New York City, including 382 clients of eight of those ACT teams. Data in seven domains deemed relevant to transition readiness were used to calculate readiness scores for each client. An algorithm assigned clients to one of three categories: consider for transition, readiness unclear, and not ready. RESULTS: Via the TRS algorithm, of the 1,365 clients, 192 (14%) were assigned to the consider-for-transition group, 382 (28%) to the unclear group, and 791 (58%) to the not ready group. Clinicians on the eight ACT teams categorized 15% of their current clients in the consider-for-transition group, whereas the TRS algorithm classified 18% in this category. Overall, the TRS agreed with the category assigned by ACT team clinicians in 69% of cases. CONCLUSIONS: The TRS may provide ACT teams and program administrators with a tool to identify clients who may be ready to transition to less intensive services, thereby opening scarce slots. Because ACT cases are complex, data summaries can offer useful syntheses of information, particularly when data from several assessments are used to summarize a client's trajectory.

Randomized trial of critical time intervention to prevent homelessness after hospital discharge.

OBJECTIVE: This study assessed the effectiveness of a previously tested model, critical time intervention (CTI), in producing an enduring reduction in the risk of homelessness for persons with severe mental illness who were discharged from inpatient psychiatric treatment facilities. METHODS: A total of 150 previously homeless men and women with severe mental illness and who were discharged from inpatient psychiatric hospitalization to transitional residences on the hospital grounds were randomly assigned to receive usual care or usual care plus CTI at the point of discharge to the community. The nine-month intervention aims to gradually pass responsibility to community sources for providing ongoing support after the intervention ends, thereby leading to a durable reduction in risk of future homelessness. After participants were discharged from the transitional residence (length of stay six to 937 days), their housing status was assessed every six weeks for 18 months via participant self-report collected by interviewers blind to study condition. RESULTS: In an intent-to-treat analysis, participants assigned to the CTI group had significantly less homelessness at the end of the follow-up period (the final three six-week intervals) than those assigned to the control group (odds ratio=.22, 95% confidence interval=.06-.88). CONCLUSIONS: A relatively brief, focused intervention for persons with severe mental illness led to a reduction in the risk of homelessness that was evident nine months after the intervention ended. This work suggests that targeted, relatively short interventions applied at critical transition points may enhance the efficacy of long-term supports for persons with severe mental illness who are living in the community.