Critical Time Intervention for Homelessness

Overseen By Sean Kidd, PhD

Age: < 65

Sex: Any

Trial Phase: Phase 2 & 3

Sponsor: Centre for Addiction and Mental Health

Disqualifiers: Residence outside Toronto

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Prior Safety Data This treatment has passed at least one previous human trial

Approved in 1 Jurisdiction This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 12

Duration: 52 weeks

210 Participants Needed

Trial Summary

What is the purpose of this trial?

Problem Statement: This proposal addresses the problem of youth not being adequately supported as they attempt to transition out of homelessness. This problem leads to frequent cycling in and out of homelessness, protracted periods of homelessness, and increased exposure to an array of serious risks to health and wellbeing. This is not just an issue of housing. While adequate housing is necessary to youth exiting homelessness it is not, in and of itself, sufficient to ensure success in sustaining housing nor flourishing as a result of housing. Objective: This proposal tests a complex, critical time intervention for youth in transition out of homelessness. This intervention, which is team-based and comprised of integrated case management, peer support, and mental health supports, has proven feasible in pilot and feasibility trials. Its objective is to stabilize housing trajectories and improve outcomes in major life domains. Specific Aims: The primary aim of this study is to determine if the provision of 1 year of the critical time intervention HOP-C can improve the outcomes of youth who have transitioned into stable housing in the past 6 months. It is hypothesized that, compared with treatment as usual, housing, employment, education, and mental health outcomes will be significantly better for youth who receive HOP-C and that these gains will be sustained. Changes in quality of life, social supports, and psychological wellbeing will be explored as secondary outcomes. Partners: This study builds on a partnership between the Centre for Addiction and Mental Health (research capability, mental health service expertise) and two established Toronto service providers focusing on homeless youth populations (Covenant House - Toronto; LOFT Community Services). Study Design: This study is a single blind, randomized controlled trial comparing the outcomes of the transitional intervention described above with typical supports provided in the community. Assessments will be conducted at baseline, mid-point (6 months), post-intervention (1 year), and at 6 months follow up. Implications: From a trial design perspective, the proposed study would provide evidence supporting a rationale for future trials and wide implementation. Pending positive outcomes, this would flow into multisite trial and implementation grant applications and further collaborations with others working within Canada and elsewhere. More broadly, this line of investigation has synergy with the increasingly larger and better-organized movements towards addressing homelessness in Canada. These efforts have included At Home/Chez soi - the largest study to date of housing first and Making the Shift, an NCE-funded collaborative effort towards ending youth homelessness in Canada. Collectively, these developments (in which the applicants are substantively involved), present the opportunity for both scaling the critical time intervention proposed here and its ultimately being combined with other approaches (e.g., housing first, family reunification, support in transitions from protection and justice systems). Such systems-oriented strategies, girded by evidence, hold the greatest promise for ameliorating the problem of youth homelessness and homelessness overall in Canada.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It focuses on providing support for youth transitioning out of homelessness, so it's best to discuss your medications with the trial coordinators.

What data supports the effectiveness of the treatment Housing Outreach Project Collaboration (HOP-C) and Critical Time Intervention for homelessness?

Research shows that the Housing Outreach Project Collaboration (HOP-C) and Critical Time Intervention can help people experiencing homelessness by improving their connection to mental health services, education, and employment. These programs have been found to increase housing stability and reduce hospital visits, making them promising approaches for supporting individuals transitioning out of homelessness. ^{1 2 3 4 5}

Is Critical Time Intervention (CTI) safe for humans?

The available research does not specifically address safety concerns for Critical Time Intervention (CTI) or its variants like Housing Outreach Project Collaboration (HOP-C). However, these interventions focus on providing support and services, which generally do not pose direct safety risks to participants. ^{5 6 7 8 9}

How is the Critical Time Intervention for Homelessness treatment different from other treatments?

The Critical Time Intervention for Homelessness, specifically the Housing Outreach Project Collaboration (HOP-C), is unique because it combines transitional outreach-based case management, individual and group mental health supports, and peer support to help individuals transition out of homelessness. This multiagency, interdisciplinary approach focuses on building connections to services and fostering independence, which is different from other treatments that may not offer such comprehensive support. ^{2 3 6 10 11}

Eligibility Criteria

This trial is for young people aged 16-25 in Toronto who have been homeless for at least 6 months but recently found stable housing (from 1 day to 6 months ago). They must speak English well. It's not for those planning to move out of Toronto within a year.

Inclusion Criteria

Proficiency in English

Participants will have been in stable housing for between 1 day and 6 months

I am between 16 and 25 years old.

Exclusion Criteria

Has transitioned to a residence outside of Toronto or plans to do so within the coming year.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive the critical time intervention HOP-C for 1 year, including integrated case management, peer support, and mental health supports

52 weeks

Baseline, mid-point (6 months), post-intervention (1 year)

Follow-up

Participants are monitored for housing stability, quality of life, and mental health outcomes

6 months

6 months follow-up

Treatment Details

Interventions

• Housing Outreach Project Collaboration (HOP-C)

Trial Overview The study tests the HOP-C program, which includes team-based case management, peer support, and mental health services. The goal is to see if it helps youth stay housed and improve their life outcomes compared to usual community supports.

Participant Groups

Group I: Housing Outreach Project - Collaboration (HOP-C) + Treatment as Usual Experimental Treatment 1 Intervention

The treatment condition is HOP-C plus treatment as usual (TAU).

Group II: Treatment As Usual Active Control 1 Intervention

TAU for this population reflects the standard array of services accessed by transitional youth populations. Most will have some contact with a youth worker with ranging focus and intensity (none likely to receive case management at HOP-C intensity), and very few will have any routine contact with other professionals or peer support. They may have some sporadic access to skills development programs and primary healthcare providers with mental health and addictions needs addressed primarily through emergency services at times of crisis.

Housing Outreach Project Collaboration (HOP-C) is already approved in Canada for the following indications:

Approved in Canada as HOP-C for:

• Youth homelessness stabilization
• Mental health support

Who Is Running the Clinical Trial?

Centre for Addiction and Mental Health

Lead Sponsor

Trials

388

Recruited

84,200+

LOFT Community Services

Collaborator

Wellesley Institute

Collaborator

Trials

1

Recruited

210+

LOFT Community Services

Collaborator

Trials

4

Recruited

490+

Covenant House Toronto

Collaborator

Trials

5

Recruited

330+

Findings from Research

Patients experiencing homelessness face significant health challenges and high hospital utilization, indicating a need for better housing coordination within healthcare systems.

Implementing a housing coordination framework that connects hospital-based and outpatient housing navigators could improve health outcomes and reduce healthcare costs for this vulnerable population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Health system-based housing navigation for patients experiencing homelessness: A new care coordination framework. Velasquez, DE., Mecklai, K., Plevyak, S., et al.[2022]

The Housing Outreach Program-Collaboration (HOP-C) was a 6-month intervention for homeless youth that successfully engaged 31 participants, with 28 completing the program, indicating strong feasibility for this multiagency approach.

Participants showed modest improvements in self-reported metrics, but significant gains were noted in employment, education, and mental health service connections, highlighting the potential effectiveness of a flexible, comprehensive support system.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

More than four walls and a roof needed: A complex tertiary prevention approach for recently homeless youth. Kidd, SA., Vitopoulos, N., Frederick, T., et al.[2020]

The HOP-C North program, adapted for Indigenous youth in Thunder Bay, showed promising preliminary effectiveness, with participants reporting improvements in educational enrollment, employment, and mental health service engagement after the program.

Key aspects of the program that contributed to its success included flexibility, accessibility, strong relationships, and a focus on participant autonomy, highlighting the importance of tailoring interventions to meet the unique needs of Indigenous youth experiencing homelessness.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adaption and implementation of the Housing Outreach Program Collaborative (HOP-C) North for Indigenous youth. Toombs, E., Mushquash, CJ., Lund, J., et al.[2022]

Both Critical Time Intervention (CTI) and Assertive Community Treatment (ACT) models were effective in helping individuals with co-occurring disorders transition from homelessness to stable housing, with significant reductions in homelessness observed after 6 months (30% for ACT and 44.3% for CTI).

Participants in the CTI program experienced notable improvements in their mental health and substance use, indicating that this model not only aids in housing stability but also supports recovery from psychiatric symptoms and substance use issues.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Case Management Models in Permanent Supported Housing Programs for People With Complex Behavioral Issues Who Are Homeless. Clark, C., Guenther, CC., Mitchell, JN.[2022]

The Housing Outreach Program-Collaboration (HOP-C) is a promising intervention for youth transitioning out of homelessness, showing feasibility and improved outcomes in mental health, employment or education, and housing stability in a pilot study of 65 participants.

Participants receiving HOP-C had significantly better subjective housing stability and higher odds of positive outcomes compared to those receiving standard transitional case management, suggesting the need for further testing in a larger trial.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Trialing the feasibility of a critical time intervention for youth transitioning out of homelessness. Kidd, SA., Vitopoulos, N., Frederick, T., et al.[2021]

Critical Time Intervention (CTI) has been shown to significantly reduce homelessness and increase service engagement among various populations, based on a systematic review of 13 studies.

While CTI demonstrates effectiveness in improving outcomes during life transitions, the exact mechanisms behind its positive impacts are still not well understood.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Supporting Vulnerable People During Challenging Transitions: A Systematic Review of Critical Time Intervention. Manuel, JI., Nizza, M., Herman, DB., et al.[2023]

The HEALing Communities Study (HCS) is testing a community-based intervention called Communities That HEAL (CTH) in 67 communities across four states to enhance the implementation of evidence-based practices (EBPs) aimed at reducing opioid-involved overdose deaths.

Coalitions in these communities will select at least five strategies to implement EBPs, including overdose education and naloxone distribution, and access to medications for opioid use disorder, ensuring a tailored approach to local needs and contexts.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Protocol for community-driven selection of strategies to implement evidence-based practices to reduce opioid overdoses in the HEALing Communities Study: a trial to evaluate a community-engaged intervention in Kentucky, Massachusetts, New York and Ohio. Young, AM., Brown, JL., Hunt, T., et al.[2022]

A local initiative called Project H3 successfully housed 47 medically vulnerable homeless individuals, with 98% of participants remaining in their homes after 12 months.

Participants reported significant improvements in healthcare access, quality of life, and a decrease in criminal justice involvement, highlighting the effectiveness of housing first, harm reduction, and peer support models in supporting homeless populations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The impact of housing first and peer support on people who are medically vulnerable and homeless. Bean, KF., Shafer, MS., Glennon, M.[2022]

The Copenhagen Hospital Corporation successfully implemented a reporting system for adverse events, resulting in 6011 reported incidents over three years, indicating a strong safety culture among staff.

The organization conducted 92 root cause analyses during this period, focusing on both optional and mandatory reports, which highlights their commitment to understanding and preventing future adverse events.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Adverse events management. Methods and results of a development project]. Rabøl, LI., Jensen, EB., Hellebek, AH., et al.[2006]

The study aims to develop and test a distance-based implementation strategy for the Housing First model (HFM), which has been shown to significantly improve outcomes for chronically homeless individuals.

By involving ten housing providers in Chicago and Central Indiana, the research will gather both qualitative and quantitative data to refine the implementation strategy, potentially enhancing the scalability and effectiveness of HFM in diverse settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Development and testing of an implementation strategy for a complex housing intervention: protocol for a mixed methods study. Watson, DP., Young, J., Ahonen, E., et al.[2022]

Critical Time Intervention (CTI) effectively helps prevent recurrent homelessness in individuals with severe mental illness by improving continuity of care during their transition from institutional settings to community living.

The model has shown promise in real-world applications, as illustrated by a case example of a homeless woman successfully transitioning from a shelter to stable housing, highlighting its potential for broader adaptation and implementation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Critical Time Intervention: an empirically supported model for preventing homelessness in high risk groups. Herman, D., Conover, S., Felix, A., et al.[2022]

References

1. Netherlands pubmed.ncbi.nlm.nih.gov

Health system-based housing navigation for patients experiencing homelessness: A new care coordination framework. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

More than four walls and a roof needed: A complex tertiary prevention approach for recently homeless youth. [2020]

3. United States pubmed.ncbi.nlm.nih.gov

Adaption and implementation of the Housing Outreach Program Collaborative (HOP-C) North for Indigenous youth. [2022]

4. United States pubmed.ncbi.nlm.nih.gov

Case Management Models in Permanent Supported Housing Programs for People With Complex Behavioral Issues Who Are Homeless. [2022]

5. United States pubmed.ncbi.nlm.nih.gov

Trialing the feasibility of a critical time intervention for youth transitioning out of homelessness. [2021]

6. United States pubmed.ncbi.nlm.nih.gov

Supporting Vulnerable People During Challenging Transitions: A Systematic Review of Critical Time Intervention. [2023]

7. England pubmed.ncbi.nlm.nih.gov

Protocol for community-driven selection of strategies to implement evidence-based practices to reduce opioid overdoses in the HEALing Communities Study: a trial to evaluate a community-engaged intervention in Kentucky, Massachusetts, New York and Ohio. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

The impact of housing first and peer support on people who are medically vulnerable and homeless. [2022]

9. Denmark pubmed.ncbi.nlm.nih.gov

[Adverse events management. Methods and results of a development project]. [2006]

10. England pubmed.ncbi.nlm.nih.gov

Development and testing of an implementation strategy for a complex housing intervention: protocol for a mixed methods study. [2022]

11. Netherlands pubmed.ncbi.nlm.nih.gov

Critical Time Intervention: an empirically supported model for preventing homelessness in high risk groups. [2022]