The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

David Ponka; Eric Agbata; Claire Kendall; Vicky Stergiopoulos; Oreen Mendonca; Olivia Magwood; Ammar Saad; Bonnie Larson; Annie Huiru Sun; Neil Arya; Terry Hannigan; Kednapa Thavorn; Anne Andermann; Peter Tugwell; Kevin Pottie

doi:10.1371/journal.pone.0230896

Peer Review History

Original SubmissionJuly 26, 2019
28 Nov 2019 Decision Letter - Stefano Federici, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-19-19380 The Effectiveness of Case-Management Interventions for the Homeless, Vulnerably Housed and Persons with Lived Experience: A Systematic Review and Meta-Analysis PLOS ONE Dear Dr. Pottie, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The manuscript was reviewed by three reviewers. Although all Reviewers appreciated the importance of the subject and the good style of writing, they do raise the relevant methodological shortcomings of the manuscript that need to be thoroughly reviewed. In particular, Reviewers raise doubts about the correctness of the statistical analyses with reference to the meta-analysis. The Reviewers note that Discussions also need to be reviewed. Therefore, I suggest that the Authors proceed to address all the Reviewers’ comments to make the manuscript suitable for publication. We would appreciate receiving your revised manuscript by Jan 12 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Stefano Federici, Ph.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 1. Please upload a copy of Figures 3 &4, to which you refer in your text on page 36. If the figure is no longer to be included as part of the submission please remove all reference to it within the text. Additional Editor Comments (if provided): The manuscript was reviewed by three reviewers. Although all Reviewers appreciated the importance of the subject and the good style of writing, they do raise the relevant methodological shortcomings of the manuscript that need to be thoroughly reviewed. In particular, Reviewers raise doubts about the correctness of the statistical analyses with reference to the meta-analysis. The Reviewers note that Discussions also need to be reviewed. Therefore, I suggest that the Authors proceed to address all the Reviewers’ comments to make the manuscript suitable for publication. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly Reviewer #3: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: No ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is a review article on case management interventions for persons who are homeless or otherwise unstably housed, focused on ACT, ICM, and CTI. The effects of these interventions on health and social outcomes are discussed, as well as the quality of the evidence surrounding each intervention. These interventions are critical for improving care for a very vulnerable population and a systematic evaluation of the evidence surrounding these practices is valuable. The article is well-written. Some specific comments are offered below. Abstract • The conclusions of the abstract reflect the need to balance fidelity to an intervention’s components (used to achieve outcomes shown in research settings) and adaptation to meet the real-world context of under-resourced settings. To that end, might be good to add a sentence to the background of the abstract highlighting the clinical relevance of this review, i.e., what is the utility of studying these case management approaches with regards to real world care. • There seems to be a comparison between mainstream case management and three more intensive CM models, but mainstream CM is not mentioned in the abstract Introduction • The first sentence references structural challenges (of which there are many) - however, the second sentence describes individual level factors that are barriers to care, as opposed to structural challenges. • Table 1 o SCM - is this limited to persons engaging in primary care? I think that routine case management happens for many homeless individuals who receive social services but who do not receive health care services in primary care settings. A concern for throughout the manuscript is that SCM is very challenging to define and very diverse across settings and studies. o CTI - generally this model is not just with any transition, but the transition between an institutional setting to community living • Interested to hear more about how the Delphi consensus panel helped prioritize interventions of interest - were SCM, ICM, CTI, ACT selected because of this panel? A few sentences about this in the methods as opposed to the intro might be helpful. Results • The Hurlbu study (SCM) is a HUD-VASH study, which is a PSH program (I thought these were excluded to be part of a separate review) • Clark et al (2003) - the comprehensive housing program sounds very much like PSH • The findings on ACT - findings on hospitalization were mostly positive, which I think is consistent with the literature. How does this work juxtaposed with the assertion that benefits of ACT on mental health outcomes were minimal - hospitalization is generally a proxy for mental health outcomes. • Cost effectiveness: how could total cost incurred by SCM clients be greater than total cost for ACT clients? Discussion • Appreciate the recognition at the top of the discussion that the interventions, populations, and outcomes were heterogeneous, which makes it hard to analyze the data - it would be good to have this sort of statement up front at the end of the introduction statement • A fundamental question is if SCM is good for a different subgroup of homeless people than the more intensive interventions studied. Or, is SCM just too low intensity for homeless people, but acceptable for a less vulnerable population? The article basically says that more intensive case management is needed for everyone in this population - I’m not sure that is true, as there has got to be some match between clinical acuity and the acuity of the CM intervention needed; SCM is also such a broad and vague term encompassing many different things in studies and in real-world settings • There is a statement in the discussion that persons with lived experience were integrated on the research team - not clear how this took place or in what capacity they were involved in these analyses Reviewer #2: Thank you for the opportunity to review this interesting manuscript. Since I am not an expert in the topic, my comments will focus on the systematic review and meta-analysis methodology and reporting. Major Concern: The results of this systematic review and meta-analysis should focus more on the meta-analytic findings. Nearly all of the results presented resort to counting p-values or describing the findings from specific studies. The beauty of meta-analysis is to move beyond p-counting so that you can show the overall effect of a type of intervention. Of the 56 studies in this review, I’m only seeing 3 studies meta-analyzed, for only two outcomes. No rationale is provided for why a meta-analysis was not performed on any other outcomes. Even the narrative review results are rudimentary, with very little synthesis reported. Additional comments: 1. The protocol has not been published, so reviewers only have the limited methods section to use to evaluate the review methods. While the methods appear to be rigorous, more detail would be helpful, particularly in the data analysis section. Also, the author guidelines for PLOS One state that systematic reviews without published protocols should include the protocol in the supplementary material. 2. Was the protocol registered with a systematic review registry, such as PROSPERO? I did not see a PROSPERO registration number mentioned. PLOS One submission guidelines require the protocol registry number to be included in the abstract. 3. Please address in the methods how you managed studies that had multiple interventions using the same control group in your meta-analyses. 4. The PRISMA flow diagram should include a summary of the reasons for exclusion for the 214 studies excluded at the full-text review stage in the original search. Don’t just make readers go to the supplementary files and then expect the reader to count the reasons themselves. While I admire the level of detail you’re including in your tables and supplementary files, the whole point of a review is to summarize and synthesize for readers. 5. Table 9 needs a legend that defines the abbreviations for the intervention types. 6. On p. 35, line 189, the word “trivial” may not be the best word choice, as it can imply a value judgement. Perhaps something like “equivocal” would be better? 7. Are Figures 1 and 2 data from just one study? This is not clear from the figures alone, as there is no study cited, and forest plots typically imply meta-analytic results across studies. 8. The figures on page 36 are not labeled. Reviewer #3: Overall, this is a well-written analysis of case management interventions of homeless or vulnerably-housed individuals. This is not my field of study, so I cannot comment on the relevance of this review to this field or the quality of the qualitative analysis portion, other than to say that it was thorough. However, I have some concerns regarding the meta-analysis. It seems improper to use a random-effects meta-analysis in a meta-analysis including only 2 or 3 studies. My suspicion is that, in practice, your conclusion that ICM reduces number of days homeless will be robust to either approach: fixed effects vs. random effects, but it would be encouraging to know that the random effects approach has not under-estimated the confidence intervals on the pooled effect. I would recommend repeating the analyses from the figures on page 36 using a fixed effects approach (basically an inverse-variance weighted average of the studies) and indicate whether the results were similar or not to the random effects results. Minor comments: Tables 4-8 should go into a supplemental material file. This is a thorough summary of all of these studies and way too much information for the text of the manuscript. Figures 1 and 2: Are these from a single study? If so, I don't understand why it's necessary to present these findings that have been presented elsewhere. I would recommend dropping these figures and succinctly summarizing the results in the text. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Sonya Gabrielian Reviewer #2: No Reviewer #3: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0230896.r001
Revision 1
30 Dec 2019 Author Response Kevin Pottie, MD CCFP MCISc FCFP 85 Primrose Ave, room 307, Ottawa, ON kpottie@uottawa.ca Re: The Effectiveness of Case-Management Interventions for the Homeless, Vulnerably Housed and Persons with Lived Experience: A Systematic Review and Meta-Analysis (reference number PONE-D-19-19380) Response to editors and peer-reviewers ________________________________________ Editorial comments Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming Response: Thank you. We have reviewed PLOS ONE’s style requirements and have edited our manuscript as necessary. Please upload a copy of Figures 3 &4, to which you refer in your text on page 36. If the figure is no longer to be included as part of the submission please remove all reference to it within the text. Response: Figures 3 and 4 are the forest plots representing our pooled meta-analyses. We have uploaded them separately as per your request. Peer reviewers’ comments Reviewer #1 This is a review article on case management interventions for persons who are homeless or otherwise unstably housed, focused on ACT, ICM, and CTI. The effects of these interventions on health and social outcomes are discussed, as well as the quality of the evidence surrounding each intervention. These interventions are critical for improving care for a very vulnerable population and a systematic evaluation of the evidence surrounding these practices is valuable. The article is well-written. Some specific comments are offered below. Response: Thank you for taking the time to review our manuscript and highlight the importance of such a comprehensive review of the literature on the effectiveness and cost effectiveness of case management interventions among homeless and vulnerably housed populations. We have addressed your comments and feedback. Kindly see our responses below. Abstract • The conclusions of the abstract reflect the need to balance fidelity to an intervention’s components (used to achieve outcomes shown in research settings) and adaptation to meet the real-world context of under-resourced settings. To that end, might be good to add a sentence to the background of the abstract highlighting the clinical relevance of this review, i.e., what is the utility of studying these case management approaches with regards to real world care. Response: Thank you for this comment. The definitions of case management models in the very heterogeneous literature makes this addition very relevant. This also links to your comment below about SCM which we address further. In fact, our conclusions reflect the need to better understand the link between intensity and effect, especially in complex and variable primary care settings. • There seems to be a comparison between mainstream case management and three more intensive CM models, but mainstream CM is not mentioned in the abstract Response: Thank you for highlighting this discrepancy. We have added to our abstract findings of mainstream case management Introduction • The first sentence references structural challenges (of which there are many) - however, the second sentence describes individual level factors that are barriers to care, as opposed to structural challenges. Response: Thank you, we have amended these sentences to improve clarity. • Table 1 o SCM - is this limited to persons engaging in primary care? I think that routine case management happens for many homeless individuals who receive social services but who do not receive health care services in primary care settings. A concern for throughout the manuscript is that SCM is very challenging to define and very diverse across settings and studies. Response: Thank you for this comment. We agree that SCM is very heterogeneous. We have added additional remarks to that effect on our introduction. SCM is also not limited to persons engaging in primary care, although it is common. We have revised Table 1 to reflect that SCM may be delivered to persons with complex care needs. o CTI - generally this model is not just with any transition, but the transition between an institutional setting to community living Response: We sought evidence on critical time interventions that aimed to help individuals transition from a state of precarious housing and into more stable accommodation. As a result of our search, we found evidence on three CTI trials that assist individuals transition from shelters to more stable housing as well as one trial devising a transition plan after discharge from the hospital. Thank you for you comment. We will make this more clear in Table 1 and the results section. • Interested to hear more about how the Delphi consensus panel helped prioritize interventions of interest - were SCM, ICM, CTI, ACT selected because of this panel? A few sentences about this in the methods as opposed to the intro might be helpful. Response: Thank you for this comment. We have provided additional details in the methods (see section “Selection of priority interventions”) regarding the Delphi process and the rationale for choosing these models of case management. Results • The Hurlbut study (SCM) is a HUD-VASH study, which is a PSH program (I thought these were excluded to be part of a separate review) Response: Thank you. Even though the Hurlburt study is part of the HUD-VASH project. The findings of the two publications reported on the added benefits of providing case management to participants regardless of their housing arrangements. We sought evidence on every study that reported on the benefits (or harms, if found) of case management interventions, and thus we have included these publications for that purpose. • Clark et al (2003) - the comprehensive housing program sounds very much like PSH Response: You are correct. The comprehensive housing program is very much a replication of PSH. However, participants allocated to the other arm of this trial are provided with case management services only. We included this study in our analysis to assess whether case management only was superior or equivalent to PSH in improving our outcomes of interest. • The findings on ACT - findings on hospitalization were mostly positive, which I think is consistent with the literature. How does this work juxtaposed with the assertion that benefits of ACT on mental health outcomes were minimal - hospitalization is generally a proxy for mental health outcomes. Response: We agree and have rephrase the sentence to reflect the reasonably positive effects of ACT interventions in reducing in psychiatric symptoms across studies. • Cost effectiveness: how could total cost incurred by SCM clients be greater than total cost for ACT clients? Response: Thank you for your comments. The total cost of SCM was higher than ACT in the case when the studies included all cost components incurred to society (termed the ‘societal perspective’). Specifically, the slightly higher cost of SCM was due to the fact that SCM clients had nominally more frequent visits to outpatient health care and other community services, more arrest episodes, and incurred higher family time costs compared to ACT clients. We have clarified this point in the cost and cost-effectiveness section. Discussion • Appreciate the recognition at the top of the discussion that the interventions, populations, and outcomes were heterogeneous, which makes it hard to analyze the data - it would be good to have this sort of statement up front at the end of the introduction statement Response: We agree, and have provided two sentences at the end of the introduction to highlight the heterogeneity of the interventions at hand. • A fundamental question is if SCM is good for a different subgroup of homeless people than the more intensive interventions studied. Or, is SCM just too low intensity for homeless people, but acceptable for a less vulnerable population? The article basically says that more intensive case management is needed for everyone in this population - I’m not sure that is true, as there has got to be some match between clinical acuity and the acuity of the CM intervention needed; SCM is also such a broad and vague term encompassing many different things in studies and in real-world settings Response: Thank you very much for these thoughtful questions. We agree that the definition of SCM is challenging and thus decided to take a broad approach. We attempted to distinguish the differences in CM in Table 1. However, comparing SCM to more intensive models was not the focus of the review, and indeed such a comparison would likely be based on comparable populations - per Table 1, the more intensive approaches in fact aimed at specific subsets of homeless popullations. Because of all these factors, not to mention that issues of fidelity that you raise, we tempered the strength of our conclusions. • There is a statement in the discussion that persons with lived experience were integrated on the research team - not clear how this took place or in what capacity they were involved in these analyses Response: Thank you for highlighting the shortage in describing the role of our people with lived experience of homelessness in this project. We have provided more information regarding this issue in the methods section. Reviewer #2: Thank you for the opportunity to review this interesting manuscript. Since I am not an expert in the topic, my comments will focus on the systematic review and meta-analysis methodology and reporting. Response: Thank you for reviewing our work and providing feedback on our methods. An important strength of our review is the rigorous methodology we have used in screening, data collection and management, data analysis, and reporting processes. We have addressed all your comments. Kindly find our responses below. Major Concern: The results of this systematic review and meta-analysis should focus more on the meta-analytic findings. Nearly all of the results presented resort to counting p-values or describing the findings from specific studies. The beauty of meta-analysis is to move beyond p-counting so that you can show the overall effect of a type of intervention. Of the 56 studies in this review, I’m only seeing 3 studies meta-analyzed, for only two outcomes. No rationale is provided for why a meta-analysis was not performed on any other outcomes. Response: Thanks, meta-analysis is one of the most robust statistical methods to synthesize outcome data to provide a quantitative estimate and we used this method whenever outcome data permitted. We attempted to meta-analyze all outcomes, but heterogeneity in interventions, outcomes and time-points precluded this for the majority of outcomes. We have clarified this in the methods section. Even the narrative review results are rudimentary, with very little synthesis reported. Response: Thank you. It appears we did not clearly describe our synthesis. Given that the majority of our synthesis is narrative, we have referred to the SWiM (Synthesis Without Meta-Analysis) reporting guidelines (previously named “Improving the Conduct and reporting of Narrative Synthesis of Quantitative data (ICONS-Quant)”), which is presently under consideration for publication (must be kept confidential). The ICONS-Quant items are intended to complement PRISMA. ICONS-Quant relates to the methods and reporting of narrative synthesis, while PRISMA relates to the entire systematic review process. We have modified our paper to reflect these reporting items. Additional comments: 1. The protocol has not been published, so reviewers only have the limited methods section to use to evaluate the review methods. While the methods appear to be rigorous, more detail would be helpful, particularly in the data analysis section. Also, the author guidelines for PLOS One state that systematic reviews without published protocols should include the protocol in the supplementary material. Response: Thank you for this comment. Our protocol was published during the peer-review period. We have updated our reference list and provide a DOI to the open-access publication for reviewers to consider. Please see: https://doi.org/10.1002/cl2.1048 2. Was the protocol registered with a systematic review registry, such as PROSPERO? I did not see a PROSPERO registration number mentioned. PLOS One submission guidelines require the protocol registry number to be included in the abstract. Response: Thank you for this question. We registered our title (2018) and protocol (2019) with the Campbell Collaboration, which is considered a systematic review registry. We have made this more explicit in our manuscript under “Methods”. We have updated our reference list and provide a DOI to the open-access publication for reviewers to consider. 3. Please address in the methods how you managed studies that had multiple interventions using the same control group in your meta-analyses. Response: Thank you for this comment. We have added the following to our methods section to clarify this point: To prevent double-counting of outcomes, individual records were carefully screened to identify unique trial studies. Each study was then evaluated for potential overlap using study design, enrollment and data collection dates, authors and their associated affiliations and the reported selection and eligibility criteria in the studies to inform the assessment. Studies deemed to be at risk for double-counting were discussed by the research team and decisions for inclusion in meta-analysis (and any additional analyses) were made. 4. The PRISMA flow diagram should include a summary of the reasons for exclusion for the 214 studies excluded at the full-text review stage in the original search. Don’t just make readers go to the supplementary files and then expect the reader to count the reasons themselves. While I admire the level of detail you’re including in your tables and supplementary files, the whole point of a review is to summarize and synthesize for readers. Response: Thank you for this comment. We have updates this figure with the following information: Excluded studies n=214 Reasons: Wrong study design n=51 Irrelevant outcomes n=8 Wrong population n=25 Wrong intervention n=117 Wrong publication type n=117 10 Could not be retrieved n=3 5. Table 9 needs a legend that defines the abbreviations for the intervention types. Response: Thank you, we have added a legend to this table which defines the abbreviations. 6. On p. 35, line 189, the word “trivial” may not be the best word choice, as it can imply a value judgement. Perhaps something like “equivocal” would be better? Response: Thank you for this suggestion, we have made the appropriate changes. 7. Are Figures 1 and 2 data from just one study? This is not clear from the figures alone, as there is no study cited, and forest plots typically imply meta-analytic results across studies. Response: Thank you, these figures have been removed. 8. The figures on page 36 are not labeled. Response: Thank you, we have received feedback against using these forest plots in our results section as they come from the same study, and therefore, we have decided to replace them with a descriptive synthesis of evidence from these studies. Reviewer #3: Overall, this is a well-written analysis of case management interventions of homeless or vulnerably-housed individuals. This is not my field of study, so I cannot comment on the relevance of this review to this field or the quality of the qualitative analysis portion, other than to say that it was thorough. However, I have some concerns regarding the meta-analysis. It seems improper to use a random-effects meta-analysis in a meta-analysis including only 2 or 3 studies. My suspicion is that, in practice, your conclusion that ICM reduces number of days homeless will be robust to either approach: fixed effects vs. random effects, but it would be encouraging to know that the random effects approach has not under-estimated the confidence intervals on the pooled effect. I would recommend repeating the analyses from the figures on page 36 using a fixed effects approach (basically an inverse-variance weighted average of the studies) and indicate whether the results were similar or not to the random effects results. Response: Thank you for this comment. As per your suggestion, we have rerun the analysis using both a fixed effects model and found that our conclusions were unchanged: FIXED EFFECT MODEL: RANDOM EFFECT MODEL: However, we stand behind our original decision to publish the meta-analysis using a random effects model due to its consideration of heterogeneity. Under any interpretation, a fixed-effect meta-analysis ignores heterogeneity. In the meta-analyzed studies of our review, we have conceptual heterogeneity in populations (e.g. youth [Grace 2014] vs. mentally ill adults with children [Toro 1997] vs. chronic inebriated adults [Cox 1998]) and interventions ( time-limited ICM [Grace 2014] vs. ICM with job training [Toro 1997] vs long-term ICM [Cox 1998]). Given this conceptual heterogeneity, we could not assume that the true effect of intervention (in both magnitude and direction) is the same value in every study (i.e. fixed across studies). Instead of assuming that the intervention effects are the same, we assume that they follow (usually) a normal distribution. The assumption implies that the observed differences among study results are due to a combination of the play of chance and some genuine variation in the intervention effects. Minor comments: Tables 4-8 should go into a supplemental material file. This is a thorough summary of all of these studies and way too much information for the text of the manuscript. Response: Thank you for this suggestion, we have moved these tables to supplemental material (S4). Figures 1 and 2: Are these from a single study? If so, I don't understand why it's necessary to present these findings that have been presented elsewhere. I would recommend dropping these figures and succinctly summarizing the results in the text. Response: Thank you for this suggestion, we have removed these figures. Attachments Attachment Submitted filename: Revision 1 - Ponka et al. - Response to reviewers Nov 2019.docx https://doi.org/10.1371/journal.pone.0230896.r002
28 Jan 2020 Decision Letter - Stefano Federici, Editor PONE-D-19-19380R1 The Effectiveness of Case-Management Interventions for the Homeless, Vulnerably Housed and Persons with Lived Experience: A Systematic Review and Meta-Analysis PLOS ONE Dear Dr. Pottie, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. In this second round of review, I invite the author to take more careful consideration of the valuable notes of the Reviewers, following their suggestions and responding more fully to the objections raised. We would appreciate receiving your revised manuscript by Mar 13 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Stefano Federici, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (if provided): In this second round of review, I invite the author to take more careful consideration of the valuable notes of the Reviewers, following their suggestions and responding more fully to the objections raised. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: (No Response) Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors sufficiently addressed the concerns I mentioned in the first round of reviews. The only thing missing from the discussion section at this point from my perspective is a more nuanced reflection that homeless people have different levels of acuity and thus have different levels of need for case management intensity. That is, ACT isn't for everyone, ICM isn't for everyone, these are case management models needed for certain people with certain functional limitations and there should be some effort to match needs to services. Reviewer #2: I’d like to thank the authors for their response to the reviewer comments. I understand how challenging it is to do a project of this scope. The authors’ response to the critique about registering the systematic review is somewhat misleading. Publishing a review protocol is not the same as registering the protocol. Submitting the title to the Campbell Collaboration is not the same as listing the planned review in a publicly accessible registry prior to conducting the review. Further, the authors’ wording on p. 5 (lines 86-87) may mislead readers to think that this review was done under the auspices or sponsorship of the Campbell Collaboration (“…published by the Campbell Collaboration”), but my reading of the review protocol is that this was not the case. It might be simpler and more accurate to state that the review protocol was not registered, but was published in 2019 (and then cite the protocol paper). I still think that the authors’ narrative synthesis of results is rather rudimentary, but I understand that it can be difficult to write a narrative synthesis without falling into the trap of describing things study-by-study. I’d like to put in a note of support for the authors’ response to the first comment from Reviewer 3. I agree with the authors that a random effects model is the appropriate approach for meta-analyzing these types of studies, for the very reasons they give in their rationale. Ultimately, however, this manuscript is kind of a bait-and-switch. The title tempts a reader with a meta-analysis, but then out of the 56 studies included, only 3 studies were used for two (related) outcomes for only one of the types of case management. I have a genuine concern that the narrative review findings from this manuscript will be cited as though they are based on a meta-analysis when in fact they aren’t. While I don’t want to take away from the authors the work they did on the small meta-analysis in this paper, I also think that it might be more honest to remove “and Meta-analysis” from the title, since the overwhelming majority of this review’s findings are not based on meta-analysis. Reviewer #3: Regarding the fixed effects vs. random effects issue, the problem isn't that you don't have heterogeneity. The problem is that it's hard to quantify the heterogeneity with only 2-3 studies. The fact that the fixed effects analysis has qualitatively similar results should be briefly mentioned in the text and the results should be added to supplemental information. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Sonya Gabrielian Reviewer #2: No Reviewer #3: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0230896.r003
Revision 2
18 Feb 2020 Author Response Ponka et al. Case Management Review (Revision 2) Response to Reviewers Feb 2020 Reviewer #1: The authors sufficiently addressed the concerns I mentioned in the first round of reviews. The only thing missing from the discussion section at this point from my perspective is a more nuanced reflection that homeless people have different levels of acuity and thus have different levels of need for case management intensity. That is, ACT isn't for everyone, ICM isn't for everyone, these are case management models needed for certain people with certain functional limitations and there should be some effort to match needs to services. Response: Thank you for reviewing our manuscript and for your helpful feedback. We agree that not all models of case management are appropriate for every individual, and that the services provided should be matched to client needs. We have edited our discussion section and have included the following: “However, it is likely that a dose-response relationship may explain some of our findings, and that as higher intensity interventions such as ACT and ICM are more precisely defined, there may be greater attention to fidelity in their implementation (19). Alternatively, it is possible that lower intensity models work predominantly for homeless populations with less acute issues (or for those that are precariously housed), and this would suggest the importance of matching the intensity of the intervention with the acuity of need.” Reviewer #2: I’d like to thank the authors for their response to the reviewer comments. I understand how challenging it is to do a project of this scope. Response: Thank you for your support. The authors’ response to the critique about registering the systematic review is somewhat misleading. Publishing a review protocol is not the same as registering the protocol. Submitting the title to the Campbell Collaboration is not the same as listing the planned review in a publicly accessible registry prior to conducting the review. Further, the authors’ wording on p. 5 (lines 86-87) may mislead readers to think that this review was done under the auspices or sponsorship of the Campbell Collaboration (“…published by the Campbell Collaboration”), but my reading of the review protocol is that this was not the case. It might be simpler and more accurate to state that the review protocol was not registered, but was published in 2019 (and then cite the protocol paper). Response: Thank you for this feedback. You are correct; the protocol for this review was not registered in a publicly available registry and we agree that the original reporting of this in our manuscript may be misleading. We have edited this paragraph of the methods section to be explicit about this and provide an explicit statement for our reader: “We conducted a systematic review according to a published peer-reviewed protocol (29). The protocol was not registered in an open-access registry (e.g. PROSPERO) prior to publication”. Thank you for bringing this to our attention, this is an important lesson learned for the future. I still think that the authors’ narrative synthesis of results is rather rudimentary, but I understand that it can be difficult to write a narrative synthesis without falling into the trap of describing things study-by-study. Response: Thank you for this comment. Despite frequent use and longstanding concerns about the validity of narrative synthesis, there has been almost no methodological development to promote clearer methods for narrative synthesis, despite its use in nearly half of health related systematic reviews. We have attempted to tabulate meaningful results (Table 4), a data presentation method suggested by the SWiM reporting guidelines, but we do recognize the limited richness of this synthesis. We appreciate your understanding. I’d like to put in a note of support for the authors’ response to the first comment from Reviewer 3. I agree with the authors that a random effects model is the appropriate approach for meta-analyzing these types of studies, for the very reasons they give in their rationale. Response: Thank you very much for this support. We have worked hard to achieve methodological rigor in our review and are confident in this decision. Ultimately, however, this manuscript is kind of a bait-and-switch. The title tempts a reader with a meta-analysis, but then out of the 56 studies included, only 3 studies were used for two (related) outcomes for only one of the types of case management. I have a genuine concern that the narrative review findings from this manuscript will be cited as though they are based on a meta-analysis when in fact they aren’t. While I don’t want to take away from the authors the work they did on the small meta-analysis in this paper, I also think that it might be more honest to remove “and Meta-analysis” from the title, since the overwhelming majority of this review’s findings are not based on meta-analysis. Response: This is an excellent point. We agree and have removed “and meta-analysis” from our title. Reviewer #3: Regarding the fixed effects vs. random effects issue, the problem isn't that you don't have heterogeneity. The problem is that it's hard to quantify the heterogeneity with only 2-3 studies. The fact that the fixed effects analysis has qualitatively similar results should be briefly mentioned in the text and the results should be added to supplemental information. Response: Thank you, this is a good idea. We have added a sentence to our methods section stating that we ran these parallel analyses, and have written in the results section that findings were unchanged (i.e. not dependent on fixed vs. random effects models). We have included these results in Appendix S7. We appreciate your constructive feedback. Attachments Attachment Submitted filename: Revision 2 - Ponka et al. - Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0230896.r004
12 Mar 2020 Decision Letter - Stefano Federici, Editor The Effectiveness of Case-Management Interventions for the Homeless, Vulnerably Housed and Persons with Lived Experience: A Systematic Review PONE-D-19-19380R2 Dear Dr. Pottie, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. With kind regards, Stefano Federici, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #2: (No Response) Reviewer #3: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No Reviewer #3: No https://doi.org/10.1371/journal.pone.0230896.r005
Formally Accepted
27 Mar 2020 Acceptance Letter - Stefano Federici, Editor PONE-D-19-19380R2 The Effectiveness of Case Management Interventions for the Homeless, Vulnerably Housed and Persons with Lived Experience: A Systematic Review. Dear Dr. Pottie: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Prof. Stefano Federici Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0230896.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .