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

  • David Ponka,

    Roles Conceptualization, Data curation, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada

  • Eric Agbata,

    Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

    Affiliation Faculty of Health Science, University of Roehampton, London, United Kingdom

  • Claire Kendall,

    Roles Conceptualization, Data curation, Funding acquisition, Methodology, Writing – review & editing

    Affiliations C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, Department of Family Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada, Ottawa Hospital Research Institute, Ottawa, ON, Canada

  • Vicky Stergiopoulos,

    Roles Conceptualization, Data curation, Funding acquisition, Methodology, Writing – review & editing

    Affiliation Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada

  • Oreen Mendonca,

    Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

    Affiliation C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada

  • Olivia Magwood,

    Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

    Affiliation C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada

  • Ammar Saad,

    Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

    Affiliations C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

  • Bonnie Larson,

    Roles Data curation, Writing – original draft, Writing – review & editing

    Affiliation Department of Family Medicine, University of Calgary, Calgary, AB, Canada

  • Annie Huiru Sun,

    Roles Data curation, Formal analysis, Writing – review & editing

    Affiliation C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada

  • Neil Arya,

    Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

    Affiliation Department of Health Sciences, Wilfred Laurier University, Waterloo, ON, Canada

  • Terry Hannigan,

    Roles Writing – review & editing

    Affiliation C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada

  • Kednapa Thavorn,

    Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

    Affiliations Ottawa Hospital Research Institute, Ottawa, ON, Canada, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

  • Anne Andermann,

    Roles Data curation, Writing – review & editing

    Affiliation Department of Family Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada

  • Peter Tugwell,

    Roles Conceptualization, Data curation, Funding acquisition, Methodology, Writing – review & editing

    Affiliation Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

  • Kevin Pottie

    Roles Conceptualization, Data curation, Funding acquisition, Methodology, Supervision, Writing – review & editing

    Affiliations C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, Department of Family Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada



Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations.

Methods and findings

We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management.


Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.


Homeless and vulnerably housed populations have poorer health outcomes including acute and chronic illness [1], traumatic injury [1], mental health and substance use disorders [27], and mortality [8]. While often related to individual medical and complex social needs, structural challenges posed by fragmented health and social systems create a potent mix of barriers to access to health care. These include a lack of sufficient language capacity, awareness of affordable healthcare services and their location, transportation services, childcare, and reasonable wait times. When coupled with previous experiences of rejection or discrimination from service providers, these barriers further contribute to individuals failing to access appropriate and available health care [911].

To address these barriers, people who are homeless or vulnerably housed may benefit from tailored, patient-centered care with an integrated approach to community and social services [1214]. Case management (CM) is one such intervention where individual case managers respond to the complexity of navigating the healthcare system by assessing, planning and facilitating access to health and social services [15,16]. While case management interventions are heterogeneous in definition, complexity, target populations served, and modes of delivery [12], among these, four predominant models have evolved in relation to health care: standard case management (SCM), intensive case management (ICM), assertive community treatment (ACT), and critical time intervention (CTI) (See Table 1) [17].

Table 1. Characteristics of case management models- Adapted from de Vet et al. 2013 [15].

Case management has been shown to improve patient satisfaction [27], quality of life, and the utilization of community-based services among other high-risk populations [28]. However, the evidence base for CM and its implementation among homeless and vulnerably housed populations remains sparse. This review is one of a series of reviews on the effectiveness of providing interventions for homeless and/or vulnerably housed persons. The objective of this review is to assess the effectiveness and cost-effectiveness of four CM models for the health and social outcomes of homeless or vulnerably housed individuals in the following domains: housing stability, mental health, substance use, quality of life, hospitalization, employment and income.


Protocol registration and reporting

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. We followed the PRISMA checklist and SWiM (Synthesis Without Meta-Analysis) reporting guidelines when reporting our findings (see S1 File) [30,31]. Ethical approval was not required for this study.

Selection of priority interventions

We conducted a Delphi consensus process with 84 experienced healthcare practitioners and 76 persons with lived homelessness experience to prioritize person-centered and clinically meaningful priority topics, outcomes, and subgroups [32]. Among these, case management and care coordination were highly prioritized. We then scoped literature using Google Scholar and PubMed to broadly determine a list of interventions and terms relating to each of the Delphi priority topic categories. A working group was formed to arrive at a consensus and inform the final selection of interventions to be included in this review. This working group consisted of medical practitioners, allied health professionals, and community scholars (people with lived experience of homelessness or vulnerable housing) [33]. Our working group deliberated the value of systematic reviews and evidence-based guidelines on various interventions, giving significant weight to the needs and opinions of persons with lived experience of homelessness. Consensus of the working group was to describe case management interventions by level of intensity (Table 1)

Search strategy and selection criteria

A search strategy was developed and peer-reviewed by a health science librarian. We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, HTA database, NHSEED, DARE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from the inception of these databases to February 8, 2018, for studies on effectiveness, cost and cost-effectiveness. A combination of indexed terms, free text words, and MeSH headings were used (See S2 File). There were no date or language restrictions. We searched the reference lists of relevant systematic reviews for studies that met our inclusion criteria. We consulted experts in the field of homelessness and people with lived experience to identify any additional studies we may have missed. We updated our search on July 19, 2019 and deduplicated against our previous search to identify trials published since February 2018.

The results were uploaded to Rayyan reference manager software to facilitate the study selection process [34]. Teams of review authors assessed each study for inclusion in duplicate (See Table 2); disagreements were resolved through discussion or a third reviewer. All peer-reviewed studies that assessed case management interventions among homeless or vulnerably housed populations and that reported on relevant outcomes were included. We excluded articles where case management was delivered as a component of a permanent supportive housing intervention as this is covered by a parallel review [35].

Data analysis

We used a standardized data extraction sheet that included the study methodology, population, intervention, control, outcome, study limitations, and funding details. The data were extracted independently by two reviewers. Disagreements were resolved through discussion. 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. We used the Cochrane Risk-of-Bias tool to assess the quality of each study’s methodology, in duplicate [40].

Where possible, we conducted meta-analysis of measures of effectiveness using random effects models due to their consideration of heterogeneity using RevMan 5.3 software [41]. We verified that the random effects model did not under-estimate the confidence intervals by running parallel fixed effects analyses. We present the summary effects as relative risks or standardized mean differences, as appropriate. Where study heterogeneity did not allow for meta-analysis, we employed a narrative synthesis, defined as a “synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the findings of the synthesis. Whilst it can involve the manipulation of statistical data, the defining characteristic is that it adopts a textual approach to the process of synthesis to ‘tell the story’ of the findings from the included studies” [42]. We used the GRADE approach to appraise the certainty of the evidence (See Table 3) [43].


We identified 11,934 citations from bibliographic databases and an additional 17 from other sources. After removing duplicates, we screened 7,514 titles and abstracts for eligibility. We assessed 268 citations at full-text, of which 214 were excluded (See Fig 1 and S3 File). Our updated search yielded a total of 1877 additional records, of which 1869 records were screened by title and abstract after removing duplicates. We assessed 36 articles at full text, of which 34 were excluded (See Fig 2). From both searches, we included a total of 56 citations, of which 11 reported on SCM [4454], 10 on ACT [25,5563], 17 on ICM [6480], and 11 on CTI [8191]. Twelve articles provided evidence on cost-effectiveness; 3 on SCM [50,79,92]; 6 on ACT [56,59,9396]; 2 on ICM [97,98]; and 1 for CTI [89] (See Figs 1 and 2). Five of the cost-effectiveness articles were included in the effectiveness analysis as well [50,56,59,79,89]. The majority of the included studies were set in the United States, with three studies from Europe and one from Australia. All of the studies focused on homeless and vulnerably housed populations, with varying levels of participant profiles and comorbidities across studies. All trials compared case management interventions to usual care (UC) or an alternative intervention, such as rent vouchers, peer support groups or drop-in services. Appendix S4 lists the characteristics of the included studies on SCM, ICM, ACT, CTI and cost-effectiveness studies.

Fig 1. PRISMA flow diagram of search up to February 2018.

Fig 2. PRISMA flow diagram with updated search up to July 2019.

Characteristics of included studies (SCM)

The effects of all of the case management interventions are summarized in Table 4. In our risk-of-bias assessment (See S5 File), we found that the majority of studies had methodological deficiencies in randomization, allocation concealment and blinding of participants and personnel. The GRADE certainty of the evidence for critical patient-important outcomes is available in S6 File.

Table 4. Results of studies comparing assertive community treatment, intensive case management, critical time interventions, and standard case management to control services.

Effects of standard case management (SCM)

Of 11 trials on SCM, ten evaluated housing stability [4448,5054]. Only three reported significant decreases in homelessness [44,51,52]; an effect that diminished over time in one trial of a time-limited residential case management where participants in all groups accessed significant levels of services [44].

A SCM program tailored to women reduced the odds of depression at 3 months (OR 0.38 95% CI 0.14 to 0.99) but did not show improvements in their overall mental health status (MD 4.50; 95% CI -0.98 to 9.98) [53]. One trial reported higher levels of hostility (p<0.001) and depression symptoms (p<0.05) among female participants receiving nurse-led SCM compared to those receiving standard care, although no significant difference in psychological well-being was reported between these groups [49]. Two additional trials reported no impact on mental health outcomes [44,54]. Two trials reported decreased problematic substance use [44,79], and four others reported no effect on this outcome [4850,53].

Findings were equivocal for quality of life outcomes. One trial compared health advocate SCM (with or without outreach registration) to usual care [45,46]. While some quality of life domains (e.g. social isolation, sleep) favored health advocate SCM, most effects on quality of life were not significant. Another trial reported no significant benefits of nurse-led SCM on life satisfaction scores [49].

A single trial of health advocate SCM (with or without outreach registration) assessed health service utilization over three months [46]. Only five percent of all participants accessed the emergency department, with no significant difference between health advocacy or usual care groups [46]. Finally, five studies assessed the effectiveness of SCM on employment outcomes. One trial reported a significant improvement in employment over 24 months [44], whereas four trials showed no significant difference [48,50,51,54]. While one trial suggests that SCM improves access to income assistance (p<0.05) [51], no trials on SCM measured participant income as an outcome.

Effects of intensive case management (ICM)

Fourteen of sixteen trials on ICM assessed housing stability [64,65,67,68,7180]. Overall, ICM showed small positive effects on housing outcomes, with seven of these fourteen studies [67,68,72,75,7779] suggesting improvements in housing stability and the other seven reporting no effect (Table 4). A pooled analysis shows that ICM significantly reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03; See Fig 3) but had no significant effect on the number of days spent in stable housing compared to usual services (See Fig 4). These findings were unchanged regardless of whether random effects or fixed effects models were used in the analysis (See S7 File). For time-limited interventions, ICM effectively housed more participants [72], reduced time spent in community housing, streets and shelters [77], and reduced the number of moves to different residences [71]. Three other trials reported that ICM was associated with no difference on the number of days in no-rent or privately rented accommodations, better or worse accommodations, stable housing or homelessness compared to standard case management or usual services [74,75,78].

Fig 3. ICM versus usual care pooled analysis of number of days spent homeless (long term, 13+ months follow-up).

Fig 4. ICM versus usual care pooled analysis of number of days spent in stable housing (long term, 13+ months follow-up).

ICM had mixed effects on mental health outcomes. Four trials reported significant reductions in psychological symptoms [66,75,77,80], whereas seven additional trials reported no effect [64,65,70,73,74,78,79]. In two trials, positive mental health outcomes were correlated with improvements in quality of life [66,77], with an additional trial reporting better quality of life despite no significant differences in mental health [70]. Only one trial reported no effect of ICM on quality of life [74].

ICM had a significant benefit in reducing substance use in six of ten trials that measured this outcome [64,68,73,75,78,79]. ICM was associated with significant reductions in alcohol consumption [68,73,75] and reductions in problematic drug use [64,78,79].

ICM had mixed effects on participants’ hospitalization outcomes. Two studies reported significant reductions in the number of emergency department visits but not in the use of other hospital services compared to usual care [76,79]; while three additional trials reported no significant reductions in the number of days in hospital compared to usual services or support groups [7274].

Finally, the effect of ICM on income and employment outcomes was small. In one study, ICM was associated with increased number of days paid from employment [75], which was not found in four other trials [64,68,74,78]. Three studies reported that ICM was significantly associated with increased attainment of public income assistance and reduced the incidence of unmet financial need [79] among single adults [68,76]. However, among youth [71], and families [80], ICM had no impact on income obtained from employment or public assistance.

Effects of assertive community treatment (ACT)

Assertive community treatment showed promising effects on housing stability in five of seven trials that measured this outcome [5658,61,62]. Participants who received ACT reported significantly more days in community housing (p = 0.006) [58], and fewer days homeless (p<0.01) compared to usual or supportive services [61]. ACT marginally improved the number of days participants spent in stable housing compared to supportive services (p = 0.032) [62], and usual services (p = 0.09) [57]. However, two trials, one of which included a follow-up study, did not identify any housing-stability benefits of ACT over usual or supportive services [55,59,60].

The effects of ACT on mental health outcomes were moderately positive. In one trial, ACT interventions were associated with fewer psychological symptoms in the areas of unusual activity levels (p<0.03) and thought disorder (p<0.02) compared to other supportive services [62]. Six other trials reported no additional effects of ACT on mental health compared to usual or supportive services [25,5659,61]. ACT had equivocal effects on substance use outcomes. One trial showed that ACT participants with more severe alcohol use disorder experienced faster and earlier improvements in substance use compared to those with less severe alcohol-use disorder or those randomized to usual or supportive services (p<0.01) [25]; however, this difference was not significant by the end of three years. Four trials reported no additional benefits of ACT on substance use outcomes over usual or supportive services [57,59,61,62].

Findings on quality of life outcomes were mixed. One trial reported that ACT was significantly associated with better overall quality of life over 18 months compared to those receiving SCM (p<0.05) [56]. Another trial found no significant improvements for ACT over usual care in objective quality of life measures over 12 months, although ACT participants showed earlier improvement in life satisfaction rates compared to usual care at 6 months (p = 0.005) [58]. A third trial found no additional effects of ACT on quality of life outcomes compared to usual and supportive services [25].

Findings on hospitalization outcomes were mostly positive. One trial reported that ACT participants spent approximately half as many days in the hospital compared to those receiving standard case management [56]. No significant differences between groups were found on time to discharge from hospital or length of hospitalization. Another trial showed that ACT was associated with significantly fewer days hospitalized over 3 years compared to other supportive services (MD 19; p = 0.002) [25]. One trial reported fewer emergency department visits for ACT participants compared to usual care at 12 months (p = 0.009) [58], whereas another trial found no effect of ACT over usual care on either days in hospital or emergency department visits [55].

Finally, three trials reported no effect of ACT on income outcomes over usual or supportive services [56,61,62]. No trials measured employment outcomes.

Effects of critical time interventions (CTI)

Critical time interventions showed a promising effect on housing stability in three of four trials [82,85,87]. In the US context, one trial found that CTI significantly reduced the number of days spent homeless during the final 18 weeks of the study, compared to usual services (OR 0.22; 95% CI 0.06 to 0.88) [82]; however, this effect was not significant over the entire 18 months of the trial. Another trial reported a significant reduction in the average number of nights spent homeless among CTI participants compared to usual services over 18 months (Difference = -61; p = 0.003) [87]. Families that received CTI transitioned from shelter to housing more rapidly than the usual services group (MD -107.9 days; 95% CI -136.2,-79.6) [86]. Conversely, one European trial found that CTI did not have any impact on days rehoused after a 9-month period compared to usual services [81].

CTI showed little effect on mental health outcomes. However, a trial conducted among abused women reported significantly fewer symptoms of PTSD during follow-up (Adjusted MD -7.27, 95% CI -14.31 to -0.22, p = 0.04), but no effect on symptoms of depression or psychological distress [84]. In another RCT [85], families who received CTI showed mixed results on the frequency of children’s internalizing and externalizing problems.

Two RCTs examined quality of life outcomes and found no significant impact of CTI over usual services at 9 months [81,84]. As well, when looking at substance-use outcomes, CTI was associated with non-significant reductions in cannabis and alcohol use [81].

One study found that CTI was significantly associated with reduced odds of rehospitalization (OR 0.11, 95% CI 0.01 to 0.96, p = 0.07) and total number of nights hospitalized (p<0.05) in the final 18 weeks of the trial [83]. Another trial suggests that CTI reduced the total number of nights of hospitalization over 18 months but not the average length of hospital stays [88].

Finally, one trial showed no significant effect of CTI on income-related outcomes compared to usual services [89]. No trials reported on employment-related outcomes.

Cost and cost-effectiveness of the interventions

Evidence on cost and cost-effectiveness was mixed. The total cost incurred by SCM clients was higher than those receiving usual or standard care [50,79], but lower compared to a US clinical case management program that included housing vouchers and ICM [98]. Cost-effectiveness studies showed that when the benefits gained and costs borne to all payers were considered (also known as a societal perspective) SCM was not cost-effective compared to ACT for persons with serious mental disorders or those with a concurrent substance-use disorder as it was both more expensive [56,94], and was associated with more days in unstable housing [56], and poorer quality of life [94]. SCM was slightly more costly than ACT because 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. For ICM, Stergiopoulos and colleagues showed that the cost of supporting housing with ICM could be partially offset by reductions in the use of emergency shelters and in single-room occupancies [97]. ICM was reported as likely to be cost-effective when all costs and benefits to society are considered [98]. A pre-post study found that when ICM was provided to high users of emergency departments there was a net hospital cost savings of USD$132,726 [92]. For ACT, the included studies that focused on individuals with severe mental illness or dual disorders consistently showed that ACT interventions were associated with lower costs and improved health outcomes compared to the outcomes of usual care [56,59,9496]. We identified only one study on the cost-effectiveness of CTI which reported that the CTI provided to men with severe mental illness had comparable costs (US$52,574 vs. US$51,749) despite fewer nights spent homeless (508 vs. 450 nights) compared to usual services [89].


We conducted a comprehensive systematic review of four case management interventions for people who are homeless or vulnerably housed. The interventions were complex, and the study populations, intervention intensity, and outcomes were heterogeneous, making it challenging to generalize our findings. However, we can make some overarching statements to guide policy and practice. In general, standard case management showed little to no benefit across any of our outcome domains and in one trial [49], implementing SCM was associated with elevated levels of hostility and depression. We found that interventions of greater intensity, such as intensive case management, assertive community treatment and critical time intervention, did improve several outcomes of interest, most notably housing stability. ICM was found to reduce substance use in several studies and CTI to marginally reduce psychological symptoms; however, there was little impact on the quality of life across studies. ICM was associated with a reduced number of emergency department visits but not of hospital admissions, and both ACT and CTI, overall, showed significant reductions in both the number of emergency department visits and days in hospital. Only ICM was found to consistently improve income outcomes, with significant improvements in access to financial assistance and reductions in unmet financial needs. Case management interventions, especially ACT, were cost-effective for persons with complex needs, including those with severe mental illness or dual disorders, if the overall costs and benefits to patients, health care systems and society as a whole were considered.

Our findings suggest that the effectiveness of case management interventions is related both to the intensity of models as well as to their ability to address and advocate for the comprehensive needs of specific groups such as those with severe mental health conditions or those experiencing transitions in care. Findings suggested that the case management needed to be continuous, community-based and intensive so as to maintain and/or increase the gains achieved. For example, in Sosin and colleague’s trial [51], improvements in housing stability were attributed to the case worker’s advocacy for access to income benefits and help with locating housing. Not surprisingly, higher intensity case management models, which generally have lower caseloads, also include the provision of services above and beyond care coordination and incorporate outreach services, especially in the case of ICM, which is shown to have greater effects compared to other less intensive case-management models. This may be due to their capacity to address some of the underlying social determinants of health that contribute to the cycle of homelessness, such as poverty, which requires longitudinal engagement with case managers. A parallel review also suggests that case management can have significant impacts when provided in conjunction with permanent housing [35]. Given the heterogeneity of these complex interventions, we cannot be certain of the precise mechanisms and key features that promote effectiveness. 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. Some indicators from a parallel qualitative review point to a case-manager-client relationship built on trust and continuity of care and integrated services as being key factors in the success of case management programs [99]. Many programs include peers and people with lived experience acting in case management roles [100103], and while this has been identified as important to those confronted with homelessness [104106], such approaches require formal evaluation.

These findings contribute to an expanding evidence base on effective interventions for people who are homeless or vulnerably housed. Our review builds on a previous review by De Vet [15] as it incorporates evidence up to 2019 and also considers a broader definition of standard case management that includes health advocates, as well as residential and disease-specific case management. Our study includes studies from the US, Europe and Australia, allowing us to make inferences about more diverse health and social systems which are important to address homelessness as an international public health priority [15]. Overall, our findings are congruent with De Vet’s conclusions, but with some important differences. Notably, we saw fewer significant results in access to housing among recipients of CTI, likely arising from differences in healthcare and social contexts. The intensity of “usual care” in the Netherlands was high compared to the US context, where follow-up services were not typically available. Additionally, the Netherlands has an extensive social housing system; thus, reducing the short-term risk of recurrent homelessness. More recent CTI studies also suggest lower rates of rehospitalization than was found in our review. Finally, our broader inclusion criteria of SCM interventions allowed us to identify potential harms, such as higher levels of hostility and depression among case management recipients. Overall, our findings are in agreement with other earlier reviews, including those of Coldwell and Bender [23], Hwang [107], Vanderplasschen [28], and Mueser [108]. We also incorporated cost-effectiveness, and while the results were mixed, they provide important evidence on the potential economic impact of case management interventions on health care systems and society.

In the studies reviewed, the quantitative synthesis was complicated by the heterogeneity that exists across interventions. In addition, there is a lack of clarity in and overlap of the nomenclature used to define different case management interventions [12]. Furthermore, few studies provided the level of intervention detail required to make concrete recommendations with respect to the types of activities conducted, the roles and responsibilities of the case managers, and the postulated mechanisms of success that could inform future practice. Such lack of detail can further contribute to challenges in implementation and fidelity across interventions.

To our knowledge, this is the first systematic review to consider a broad range of outcomes and cost-effectiveness of these types of case-management interventions. We used high quality methods to synthesize randomized controlled trials and controlled trials, conducted meta-analyses, and used GRADE methods to assess the certainty of the effects. We integrated persons with lived experience of homelessness into our research team to ensure the relevancy of this work. Limitations include heterogeneous interventions and populations that precluded quantitative synthesis; thus, the studies were too few to allow us to conduct meta-analyses for the many included outcomes. As the majority of studies were conducted in the United States, our findings may not be generalizable to contexts with substantially different health and social systems. Poorly defined control or “usual care” groups further complicates the relative effectiveness of one case management model over another—a particular issue for SCM models. A weakness inherent to a secondary analysis is the potential for bias with respect to the reporting of results for multiple outcomes. Further, we restricted our inclusion criteria to rigorous experimental study designs, thereby, excluding observational studies that may have provided additional evidence in this area. This review is quantitative in nature and we may have excluded important findings related to case management found in the qualitative literature.

In summary, helping people who are homeless and vulnerably housed navigate and access a complex system of services yields positive outcomes in areas such as housing stability and mental health. Case management interventions may be most effective when they target specific complex populations or times of transition with more effective interventions that involve low caseloads, greater intensity and continuity of contact time, and direct service provision in addition to mere coordination. More research is needed on SCM models and their ideal target populations. Further, there is a need to more formally evaluate how to best integrate case management into delivery models such as chronic care management programs [109111], and patient medical home approaches [112,113]. We postulate that further work is required to understand how to embed such interventions in the primary care setting, given the appeal of its continuous and comprehensive nature [114,115]. We suggest future research should apply a realist lens in order to further understand the critical elements and implementation strategies of case management interventions [116,117].


The authors would like to acknowledge Doug Salzwedel for the systematic search, as well as the following working group members for technical support in screening, data extraction and/or critical appraisal: Tasnim Abdalla, Michaela Beder, German Chique-Alfonzo, Wahab Daghmach, Priya Gaba, Akalewold Gebremeskel, Samantha Green, Gilbert Habonimana, Nicole Kozloff, Victoire Kpade, Pierre Lauzon, Andrew Mclellan, Van Nguyen, Anita Palepu, Nicole Pinto, Asia Rehman, Kim Van Herk, Jean Wang, Mackenzie Wilson, Vanessa Ymele Leki. Finally, the authors would like to thank Glenna Jenkins for her editorial input.


  1. 1. Hwang SW, Bugeja AL. Barriers to appropriate diabetes management among homeless people in Toronto. CMAj. 2000;163(2):161–5. pmid:10934977
  2. 2. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384(9953):1529–40. pmid:25390578
  3. 3. Aubry T, Klodawsky F, Coulombe D. Comparing the housing trajectories of different classes within a diverse homeless population. Am J Community Psychol. 2012 Mar;49(1–2):142–55. pmid:21557093
  4. 4. Grinman MN, Chiu S, Redelmeier DA, Levinson W, Kiss A, Tolomiczenko G, et al. Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status. BMC Public Health. 2010;10(1):94.
  5. 5. Kennedy MC, Karamouzian M, Kerr T. Public health and public order outcomes associated with supervised drug consumption facilities: a systematic review. Curr HIV/AIDS Rep. 2017;14(5):161–83. pmid:28875422
  6. 6. Kerr T, Marshall BDL, Miller C, Shannon K, Zhang R, Montaner JSG, et al. Injection drug use among street-involved youth in a Canadian setting. BMC Public Health. 2009;9(1):171.
  7. 7. Torchallaa I, Strehlaub V, Lia K, Krausz M. Substance Use and Predictors of Substance Dependence in Homeless Women. Drug Alcohol Depend. 2011;118(2–3):173–9. pmid:21498010
  8. 8. Nordentoft M, Wandall-Holm N. 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. BMJ [Internet]. 2003 Jul 10;327(7406):81. Available from: pmid:12855527
  9. 9. Rosenheck R, Lam JA. Client and site characteristics as barriers to service use by homeless persons with serious mental illness. Psychiatr Serv. 1997;48(3):387–9. pmid:9057243
  10. 10. Milloy M-J, Kerr T, Bangsberg DR, Buxton J, Parashar S, Guillemi S, et al. Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting. AIDS Patient Care STDS. 2012;26(1):60–7. pmid:22107040
  11. 11. Palepu A, Milloy MJ, Kerr T, Zhang R, Wood E. Homelessness and adherence to antiretroviral therapy among a cohort of HIV-infected injection drug users. J Urban Heal. 2011;88(3):545–55.
  12. 12. Lukersmith S, Millington M, Salvador-Carulla L. What Is Case Management? A Scoping and Mapping Review. Int J Integr Care. 2016 Oct;16(4):2. pmid:28413368
  13. 13. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet (London, England). 2014 Oct;384(9953):1541–7.
  14. 14. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada. Can J public Heal. 2005;96(2):S23–9.
  15. 15. de Vet R, van Luijtelaar MJA, Brilleslijper-Kater SN, Vanderplasschen W, Beijersbergen MD, Wolf JRLM. Effectiveness of case management for homeless persons: a systematic review. Am J Public Health. 2013 Oct;103(10):e13–26. pmid:23947309
  16. 16. Schutt R, Siegfriedt J, Fawcett J. Who cares? Case management and patient navigation in a public health programme. Vol. 1, International Journal of Care and Caring. 2017. 367–387 p.
  17. 17. Morse G. A review of case management for people who are homeless: Implications for practice, policy, and research. In: Practical Lessons: The 1998 National Symposium on Homelessness Research Washington, DC, US Department of Housing and Urban Development. 1999.
  18. 18. Douglas Mental Health University Institute. Intensive Case Management (ICM) [Internet]. 2018 [cited 2019 Dec 29]. Available from:
  19. 19. Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane database Syst Rev. 2010 Oct;(10):CD007906.
  20. 20. Douglas Mental Health University Institute. Suivi Intensif (SI) [Internet]. 2017 [cited 2019 Dec 29]. Available from:
  21. 21. The Toronto Mental Health and Addictions Access Point. Frequently Asked Questions [Internet]. 2019 [cited 2019 Dec 29]. Available from:
  22. 22. The Homeless Hub. Assertive Community Treatment (ACT) Teams [Internet]. The Homeless Hub Website. 2019 [cited 2019 Dec 29]. Available from:
  23. 23. Coldwell CM, Bender WS. The Effectiveness of Assertive Community Treatment for Homeless Populations With Severe Mental Illness: A Meta-Analysis. Am J Psychiatry. 2007 Mar;164(3):393–9. pmid:17329462
  24. 24. The Homeless Hub. Intensive Case Management (ICM) Teams [Internet]. The Homeless Hub Webiste. 2019 [cited 2019 Dec 29]. Available from:
  25. 25. Essock SM, Mueser KT, Drake RE, Covell NH, McHugo GJ, Frisman LK, et al. Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatr Serv. 2006;57(2):185–96. pmid:16452695
  26. 26. Guarino K. Step-by Step: A Comprehensive Approach to Case Management. Homeless Hub. 2011;
  27. 27. Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of Case Management for “At Risk” Patients in Primary Care: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(7):e0132340. pmid:26186598
  28. 28. Vanderplasschen W, Wolf J, Rapp RC, Broekaert E. Effectiveness of different models of case management for substance-abusing populations. J Psychoactive Drugs. 2007;39(1):81–95. pmid:17523588
  29. 29. Pottie K, Mathew CM, Mendonca O, Magwood O, Saad A, Abdalla T, et al. PROTOCOL: A comprehensive review of prioritized interventions to improve the health and wellbeing of persons with lived experience of homelessness. Campbell Syst Rev [Internet]. 2019 Sep 1;15(3):e1048. Available from:
  30. 30. Primack RB, Cigliano JA, Parsons ECM, Chen C-S, Doloff JC, Waxman DJ, et al. Editorial: Coauthors gone bad; how to avoid publishing conflict and a proposed agreement for co-author teams. Biol Conserv. 2014;176:277–80.
  31. 31. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. bmj. 2020;368.
  32. 32. Shoemaker E, Kendall C, Mathew C, Crispo S, Welch V, Andermann A, et al. Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: a Delphi consensus study. submitted.
  33. 33. Kendall CE, Shoemaker ES, Crowe L, Rosenes R, Lundrigan P, Bibeau C, et al. Engagement of people with lived experience in primary care research: Living with HIV Innovation Team Community Scholar Program. Can Fam Physician. 2017;63(9):730–1. pmid:28904041
  34. 34. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016 Dec;5(1):210. pmid:27919275
  35. 35. Aubry T, Bloch G, Brcic V, Saad A, Magwood A, Abdalla T, et al. The Effectiveness of Permanent Supportive Housing and Income Assistance Interventions for Homeless, Vulnearbly Housed, and Persons with Lived Experience of Homelessness: A Systematic Review and Meta-Analysis. Submitted.
  36. 36. Kanter J. Clinical case management: definition, principles, components. Hosp Community Psychiatry. 1989 Apr;40(4):361–8. pmid:2714749
  37. 37. Silberman School of Social Work. Understanding the Critical Time Intervention Model | CTI Implementation FAQs. 2017.
  38. 38. Cochrane. What study designs should be included in an EPOC review and what should they be called? [Internet]. 2015. Available from: Study Designs About.pdf
  39. 39. The World Bank. World Bank Country and Lending Groups [Internet]. 2019. Available from:
  40. 40. Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A. A revised tool for assessing risk of bias in randomized trials In: Chandler J, McKenzie J, Boutron I, Welch V(editors). Cochrane Methods. Cochrane Database Syst Rev. 2016;10.
  41. 41. Collaboration NCCTC. Review manager (RevMan)[computer program] Version 53. Copenhagen Nord Cochrane Centre, Cochrane Collab. 2014;
  42. 42. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews. A Prod from ESRC methods Program Version. 2006;1:b92.
  43. 43. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr;336(7650):924 LP–926.
  44. 44. Conrad KJ, Hultman CI, Pope AR, Lyons JS, Baxter WC, Daghestani AN, et al. Case managed residential care for homeless addicted veterans. Results of a true experiment. Med Care. 1998 Jan;36(1):40–53. pmid:9431330
  45. 45. Graham-Jones S, Reilly S, Gaulton E. Tackling the needs of the homeless: a controlled trial of health advocacy. Health Soc Care Community. 2004 May;12(3):221–32. pmid:19777712
  46. 46. Reilly S, Graham‐Jones S, Gaulton E, Davidson E. Can a health advocate for homeless families reduce workload for the primary healthcare team? A controlled trial. Health Soc Care Community. 2004;12(1):63–74. pmid:14675366
  47. 47. Hurlburt MS, Wood PA, Hough RL. Providing independent housing for the homeless mentally ill: A novel approach to evaluating long-term longitudinal housing patterns. J Community Psychol [Internet]. 1996 Jul 1;24(3):291–310. Available from:
  48. 48. Lapham SC, Hall M, Skipper BJ. Homelessness and substance use among alcohol abusers following participation in project H&ART. J Addict Dis. 1995;14(4):41–55. pmid:8929932
  49. 49. Nyamathi A, Flaskerud JH, Leake B, Dixon EL, Lu A. Evaluating the impact of peer, nurse case-managed, and standard HIV risk-reduction programs on psychosocial and health-promoting behavioral outcomes among homeless women. Res Nurs Health. 2001 Oct;24(5):410–22. pmid:11746070
  50. 50. Nyamathi AM, Zhang S, Salem BE, Farabee D, Hall B, Marlow E, et al. A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis. J Exp Criminol. 2016;12(1):49–74. pmid:27217822
  51. 51. Sosin M, Bruni M, Reidy M. Paths and impacts in the progressive independence model: a homelessness and substance abuse intervention in Chicago. J Addict Dis. 1995;14(4):1–20. pmid:8929930
  52. 52. Towe VL, Wiewel EW, Zhong Y, Linnemayr S, Johnson R, Rojas J. A Randomized Controlled Trial of a Rapid Re-housing Intervention for Homeless Persons Living with HIV/AIDS: Impact on Housing and HIV Medical Outcomes. AIDS Behav. 2019;1–11.
  53. 53. Upshur C, Weinreb L, Bharel M, Reed G, Frisard C. A randomized control trial of a chronic care intervention for homeless women with alcohol use problems. J Subst Abuse Treat. 2015 Apr;51:19–29. pmid:25488504
  54. 54. Weinreb L, Upshur CC, Fletcher-Blake D, Reed G, Frisard C. Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention. Prim care companion CNS Disord. 2016 Apr;18(2): pmid:27486545
  55. 55. Clarke GN, Herinckx HA, Kinney RF, Paulson RI, Cutler DL, Lewis K, et al. Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. Ment Health Serv Res. 2000;2(3):155–64. pmid:11256724
  56. 56. Essock SM, Frisman LK, Kontos NJ. Cost‐effectiveness of assertive community treatment teams. Am J Orthopsychiatry. 1998;68(2):179–90. pmid:9589757
  57. 57. Fletcher TD, Cunningham JL, Calsyn RJ, Morse GA, Klinkenberg WD. Evaluation of treatment programs for dual disorder individuals: Modeling longitudinal and mediation effects. Adm Policy Ment Heal Ment Heal Serv Res. 2008;35(4):319–36.
  58. 58. Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry. 1997;54(11):1038–43. pmid:9366661
  59. 59. Morse GA, Calsyn RJ, Klinkenberg WD, Helminiak TW, Wolff N, Drake RE, et al. Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes. Community Ment Health J. 2006;42(4):377–404. pmid:16897413
  60. 60. Morse GA, Calsyn RJ, Klinkenberg WD, Cunningham J, Lemming MR. Integrated treatment for homeless clients with dual disorders: a quasi-experimental evaluation. J Dual Diagn. 2008;4(3):219–37.
  61. 61. Morse GA, Calsyn RJ, Allen G, Tempethoff B, Smith R. Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Psychiatr Serv. 1992;43(10):1005–10.
  62. 62. Morse GA, Calsyn RJ, Klinkenberg WD, Trusty ML, Gerber F, Smith R, et al. An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatr Serv. 1997 Apr;48(4):497–503. pmid:9090733
  63. 63. Kenny DA, Calsyn RJ, Morse GA, Klinkenberg WD, Winter JP, Trusty ML. Evaluation of treatment programs for persons with severe mental illness: Moderator and mediator effects. Eval Rev. 2004;28(4):294–324. pmid:15245622
  64. 64. Braucht GN, Reichardt CS, Geissler LJ, Bormann CA, Kwiatkowski CF, Kirby MW Jr. Effective services for homeless substance abusers. J Addict Dis. 1996;14(4):87–109.
  65. 65. Burnam MA, Morton SC, McGlynn EA, Petersen LP, Stecher BM, Hayes C, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. J Addict Dis. 1996;14(4):111–34.
  66. 66. Cauce AM, Morgan CJ, Wagner V, Moore E, Sy J, Weeden K, et al. Effectiveness of intensive case management for homeless adolescents: Results of a 3-month follow-up. J Emot Behav Disord. 1994;
  67. 67. Clark C, Rich AR. Outcomes of homeless adults with mental illness in a housing program and in case management only. Psychiatr Serv. 2003;54(1):78–83. pmid:12509671
  68. 68. Cox GB, Walker RD, Freng SA, Short BA, Meijer L, Gilchrist L. Outcome of a controlled trial of the effectiveness of intensive case management for chronic public inebriates. J Stud Alcohol. 1998;59(5):523–32. pmid:9718104
  69. 69. Cox GB, Meijer L, Carr DI, Freng SA. System Alliance and Support (SAS) A Program of Intensive Case Management: Seattle. Alcohol Treat Q. 1993;10(3–4):125–38.
  70. 70. Felton CJ, Stastny P, Shern DL, Blanch A, Donahue SA, Knight E, et al. Consumers as peer specialists on intensive case management teams: impact on client outcomes. Psychiatr Serv. 1995;
  71. 71. Grace M, Gill PR. Improving outcomes for unemployed and homeless young people: Findings of the YP4 clinical controlled trial of joined up case management. Aust Soc Work. 2014;67(3):419–37.
  72. 72. Korr WS, Joseph A. Housing the homeless mentally ill: Findings from Chicago. J Soc Serv Res. 1996;21(1):53–68.
  73. 73. Malte CA, Cox K, Saxon AJ. Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: A randomized controlled trial. Psychol Addict Behav. 2017;31(3):231. pmid:28481614
  74. 74. Marshall M, Lockwood A, Gath D. Social services case-management for long-term mental disorders: a randomised controlled trial. Lancet. 1995;345(8947):409–12. pmid:7853949
  75. 75. Orwin RG, Sonnefeld LJ, Garrison-Mogren R, Smith NG. Pitfalls in evaluating the effectiveness of case management programs for homeless persons: lessons from the NIAAA Community Demonstration Program. Eval Rev. 1994;18(2):153–207.
  76. 76. Rosenblum A, Nuttbrock L, McQuistion H, Magura S, Joseph H. Medical outreach to homeless substance users in New York City: preliminary results. Subst Use Misuse. 2002;37(8–10):1269–73. pmid:12180566
  77. 77. Shern DL, Tsemberis S, Anthony W, Lovell AM, Richmond L, Felton CJ, et al. Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health. 2000;90(12):1873. pmid:11111259
  78. 78. Stahler G, Shipley TE Jr, Bartelt D, Ducette J, Shandler IW. Evaluating alternative treatments for homeless substance-abusing men: outcomes and predictors of success. J Addict Dis. 1996;14(4):151–67.
  79. 79. Shumway M, Boccellari A, O’Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med. 2008 Feb;26(2):155–64. pmid:18272094
  80. 80. Toro PA, Rabideau JMP, Bellavia CW, Daeschler C V, Wall DD, Thomas DM, et al. Evaluating an intervention for homeless persons: results of a field experiment. J Consult Clin Psychol. 1997;65(3):476. pmid:9170771
  81. 81. de Vet R, Beijersbergen MD, Jonker IE, Lako DAM, van Hemert AM, Herman DB, et al. Critical Time Intervention for Homeless People Making the Transition to Community Living: A Randomized Controlled Trial. Am J Community Psychol. 2017 Sep;60(1–2):175–86. pmid:28872196
  82. 82. Herman DB, Conover S, Gorroochurn P, Hinterland K, Hoepner L, Susser ES. Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatr Serv. 2011 Jul;62(7):713–9. pmid:21724782
  83. 83. Tomita A, Herman DB. The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatr Serv. 2012 Sep;63(9):935–7. pmid:22810163
  84. 84. Lako DAM, Beijersbergen MD, Jonker IE, de Vet R, Herman DB, van Hemert AM, et al. The effectiveness of critical time intervention for abused women leaving women’s shelters: a randomized controlled trial. Int J Public Health. 2018;63(4):513–23. pmid:29299613
  85. 85. Shinn M, Samuels J, Fischer SN, Thompkins A, Fowler PJ. Longitudinal Impact of a Family Critical Time Intervention on Children in High-Risk Families Experiencing Homelessness: A Randomized Trial. Am J Community Psychol. 2015 Dec;56(3–4):205–16. pmid:26238278
  86. 86. Samuels J, Fowler PJ, Ault-Brutus A, Tang D-I, Marcal K. Time-Limited Case Management for Homeless Mothers With Mental Health Problems: Effects on Maternal Mental Health. J Soc Social Work Res. 2015 Dec;6(4):515–39.
  87. 87. Susser E, Valencia E, Conover S, Felix A, Tsai W-Y, Wyatt RJ. Preventing recurrent homelessness among mentally ill men: a”critical time” intervention after discharge from a shelter. Am J Public Health. 1997;87(2):256–62. pmid:9103106
  88. 88. Jones K, Colson P, Valencia E, Susser E. A preliminary cost effectiveness analysis of an intervention to reduce homelessness among the mentally ill. Psychiatr Q. 1994;65(4):243–56. pmid:7831412
  89. 89. Jones K, Colson PW, Holter MC, Lin S, Valencia E, Susser E, et al. Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatr Serv. 2003;54(6):884–90. pmid:12773605
  90. 90. Lennon MC, McAllister W, Kuang L, Herman DB. Capturing intervention effects over time: reanalysis of a critical time intervention for homeless mentally ill men. Am J Public Health. 2005 Oct;95(10):1760–6. pmid:16131636
  91. 91. Herman D, Opler L, Felix A, Valencia E, Wyatt RJ, Susser E. A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms. J Nerv Ment Dis. 2000 Mar;188(3):135–40. pmid:10749277
  92. 92. Okin RL, Boccellari A, Azocar F, Shumway M, O’brien K, Gelb A, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med. 2000;18(5):603–8. pmid:10999578
  93. 93. Aubry T, Goering P, Veldhuizen S, Adair CE, Bourque J, Distasio J, et al. A Multiple-City RCT of Housing First With Assertive Community Treatment for Homeless Canadians With Serious Mental Illness. Psychiatr Serv. 2016 Mar;67(3):275–81. pmid:26620289
  94. 94. Clark RE, Teague GB, Ricketts SK, Bush PW, Xie H, McGuire TG, et al. Cost-effectiveness of assertive community treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders. Health Serv Res. 1998;33(5 Pt 1):1285. pmid:9865221
  95. 95. Lehman AF, Dixon L, Hoch JS, DeForge B, Kernan E, Frank R. Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. Br J Psychiatry. 1999;174(4):346–52.
  96. 96. Wolff N. Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. Am J Psychiatry. 1997;154:341–8. pmid:9054781
  97. 97. Stergiopoulos V, Hwang SW, Gozdzik A, Nisenbaum R, Latimer E, Rabouin D, et al. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. Jama. 2015;313(9):905–15. pmid:25734732
  98. 98. Rosenheck R, Kasprow W, Frisman L, Liu-Mares W. Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry. 2003 Sep;60(9):940–51. pmid:12963676
  99. 99. Magwood O, Ymele Leki V, V K, Saad A, Alkhateeb Q, Gebremeskel A, et al. Trust and personal safety in the margins: A systematic review on the acceptability and accessibility of health and structural interventions for persons with lived experience of homelessness. PLOS ONE Press.
  100. 100. Gagne CA, Finch WL, Myrick KJ, Davis LM. Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions. Am J Prev Med. 2018;54(6, Supplement 3):S258–66.
  101. 101. Greene S, Ion A, Kwaramba G, Mwalwanda M, Caswell J, Guzha E, et al. “Trust Me, It’s Different”: Experiences of Peer Case Management of Women Living with HIV in Ontario, Canada. Vol. 32, Canadian Social Work Review. 2015. 73 p.
  102. 102. Cyr C, Mckee H, O’Hagan M, Priest R. Making the case for peer support. Ment Heal Comm Canada. 2016;2007–16.
  103. 103. Solomon P. Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatr Rehabil J. 2004;27(4):392–401. pmid:15222150
  104. 104. Frederick T, Daley M, Zahn W. Peer support work to enhance services for youth experiencing homelessness. In: Mental Health & Addiction Interventions for Youth Experiencing Homelessness. Canadian Observatory on Homelessness Press; 2018.
  105. 105. Tsai J, Rosenheck RA, Sullivan J, Harkness L. A group-intensive peer support model of case management for supported housing. Psychol Serv. 2011;8(3):251–9.
  106. 106. Weissman EM, Covell NH, Kushner M, Irwin J, Essock SM. Implementing peer-assisted case management to help homeless veterans with mental illness transition to independent housing. Community Ment Health J. 2005 Jun;41(3):267–76. pmid:16131006
  107. 107. Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions to improve the health of the homeless: a systematic review. Am J Prev Med. 2005;29(4):311. pmid:16242595
  108. 108. Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community care for severe mental illness: a review of research on case management. Schizophr Bull. 1998;24(1):37–74. pmid:9502546
  109. 109. Blumenthal D, Anderson G, Burke S, Fulmer T, K. Jha A, Long P. Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for Health and Health Care. Vol. 6, NAM Perspectives. 2016.
  110. 110. Kirst M, Im J, Burns T, Baker GR, Goldhar J, O’Campo P, et al. What works in implementation of integrated care programs for older adults with complex needs? A realist review. Int J Qual Heal care J Int Soc Qual Heal Care. 2017 Oct;29(5):612–24.
  111. 111. Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Heal care J Int Soc Qual Heal Care. 2005 Apr;17(2):141–6.
  112. 112. Kelly AM, Kratz B, Bielski M, Rinehart PM. Implementing Transitions for Youth With Complex Chronic Conditions Using the Medical Home Model. Pediatrics. 2002 Dec;110(Supplement 3):1322 LP–1327.
  113. 113. The College of Family Physicians of Canada. The Patient’s Medical Home Provincial Report Card [Internet]. 2019 [cited 2019 Dec 29]. Available from:
  114. 114. Crowley RA, Kirschner N. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Ann Intern Med. 2015 Aug;163(4):298–9. pmid:26121401
  115. 115. Rush B, Fogg B, Nadeau L, Furlong A. On the integration of mental health and substance use services and systems: Main report. Can Exec Counc Addict. 2008;
  116. 116. O’Campo P, Kirst M, Schaefer-McDaniel N, Firestone M, Scott A, McShane K. Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence. J Urban Health. 2009 Nov;86(6):965–89. pmid:19760155
  117. 117. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ Br Med J. 2015 Mar;350:h1258.