SYSTEMATIC REVIEW

Effectiveness of Case Management for Homeless Persons:

A Systematic Review
We reviewed the literature
on standard case management (SCM), intensive case
management (ICM), assertive community treatment
(ACT), and critical time intervention (CTI) for homeless
adults. We searched databases for peer-reviewed
English articles published
from 1985 to 2011 and found
21 randomized controlled trials
or quasi-experimental studies comparing case management to other services.
We found little evidence
for the effectiveness of ICM.
SCM improved housing stability, reduced substance
use, and removed employment barriers for substance
users. ACT improved housing stability and was costeffective for mentally ill and
dually diagnosed persons.
CTI showed promise for
housing, psychopathology,
and substance use and was
cost-effective for mentally ill
persons.
More research is needed
on how case management
can most effectively support
rapid-rehousing approaches
to homelessness. (Am J
Public Health. 2013;103:
e13e26. doi:10.2105/AJPH.
2013.301491)

Rene de Vet, MSc, Maurice J. A. van Luijtelaar, MSc, Sonja N. Brilleslijper-Kater, PhD, Wouter Vanderplasschen,
PhD, Marille D. Beijersbergen, PhD, and Judith R. L. M. Wolf, PhD

HOMELESSNESS IS A SERIOUS
and widespread public health
problem. In the United States and
Europe, estimates for the lifetime
prevalence of homelessness range
between 5.6% and 13.9%.1 The
global nancial crisis has negatively affected the prevalence of
homelessness. In the United States,
certain groups, such as families
and people living in suburban
and rural areas, have become
more vulnerable to homelessness.2 In Europe, austerity measures implemented after the start
of the crisis have increased poverty and homelessness, with possibly the worst to come because
of a strong time lag effect.3
Homelessness is often accompanied by other problems. People
who are homeless experience
a lower quality of life than those
who are domiciled.4,5 Several
longitudinal studies have found
that quality of life improves as
independent housing is obtained.5---7
Societal participation is limited;
many homeless persons are unemployed, have few sources of income, and have a limited social
network. They often experience
extreme poverty and a lack of
social support.8,9 Although few are
felony offenders, homeless persons
are at risk of arrest for transgressions resulting from their lifestyle
(e.g., panhandling, public intoxication, squatting, and failing to pay
nes).8,10 Moreover, estimates suggest that almost 40% of homeless
people are dependent on alcohol
and 25% on drugs. Many suffer
from a mental disorder, such as
a psychotic illness (13%), major

October 2013, Vol 103, No. 10 | American Journal of Public Health

depression (11%), or personality

disorder (23%).11 Physical health
problems are more prevalent
among this group than in the
general population.12,13 Recent
studies found that up to 73% of
homeless individuals have unmet
health needs.14,15 Consequently,
homelessness should be regarded
as a signicant and increasing
threat to public health, which
should be addressed.
In recent years, the focus of
policy measures to reduce homelessness has changed. The Homeless Emergency and Rapid Transition to Housing Act, an amendment
to the McKinney---Vento Homeless
Assistance Act, was enacted in
2009 to modernize the US Department of Housing and Urban
Developments homelessness assistance programs.16 In 2010, the
jury recommendations of the European Consensus Conference on
Homelessness laid out a road map
for ending homelessness in the
European Union.3 Both proposals
called for a shift away from the
"staircase" approach, which requires homeless persons to prove
housing readiness while transferring through shelters and transitional housing situations before
they become eligible for independent housing. The proposed alternative is a rapid-rehousing,16 or
housing-led,3 approach, which focuses on providing access to permanent independent housing as
the initial response to resolving
situations of homelessness, in conjunction with exible support services as required by the service
needs of those who are rehoused

to prevent recurrent homelessness.17 Case management has been

identied as a strategy to support
rapid rehousing, especially for
those with complex needs.3 Little
is known, however, about what
patterns of services are most
suitable to accompany housing
for different subgroups of homeless people.16,18
Since the 1980s, several models
of case management have been
developed that provide the same
basic functions: outreach, assessment, planning, linkage, monitoring, and advocacy.19,20 Services
delivered by case managers often
include practical support, help with
developing independent living
skills, acute care in crisis situations, support with medical and
psychiatric treatment, and assistance with contacts between clients and people in their social and
professional support systems.20
We focused on 4 models of
case management that have been
recommended and widely implemented for homeless persons19:
standard case management (SCM),
intensive case management (ICM),
assertive community treatment
(ACT), and critical time intervention (CTI). The models are
distinguished by the functions
they emphasize (Table 1). SCM is
a coordinated and integrated approach to service delivery, with
the goal to provide ongoing supportive care.21 ICM is typically
targeted to individuals with the
greatest service needs and prescribes more intensive services,
more frequent client contact, and
smaller individual caseloads than

de Vet et al. | Peer Reviewed | Systematic Review | e13

SYSTEMATIC REVIEW

TABLE 1Characteristics of Case Management Models for Homeless Adults

Standard Case Management21

Intensive Case Management21,22

Assertive Community Treatment21,23

Critical Time Intervention21,24

Focus of services

Coordination of services

Comprehensive approach

Comprehensive approach

Targeted to continuity of care

Target population

Homeless persons

Homeless persons with the greatest

Homeless persons with the greatest

Homeless persons at critical

service needs

service needs

transitions in their lives

Duration of services

Time limited

Ongoing

Ongoing

Time limited

Average caseload, no.

35

15

15

25

Outreach
Coordination or service provision

No
Coordination

Yes
Service provision

Yes
Service provision

Yes
Service provision and coordination

Responsibility for clients care

Case manager

Case manager

Multidisciplinary team

Case manager

Importance of clientcase

Somewhat important

Important

Important

Important

manager relationship

does SCM.22 ACT is closely related to ICM; however, in ACT

the responsibility for providing
services to clients is shared by
a multidisciplinary team that is
accessible 24 hours a day, 7 days
a week.23 CTI is an intensive
time-limited case management
approach to enhance continuity
of care by bridging the gap between services and strengthening
clients social and professional
networks. CTI is designed to be
deployed at critical moments in
the lives of clients, for instance,
when a person is about to make
a transition from a shelter to independent housing.24
To our knowledge, 4 reviews
on the effectiveness of case management for homeless adults have
been published.19,25---27 All 4 reviews underscore the effectiveness
of ACT in producing positive
outcomes for homeless people.
Nevertheless, whether ACT is
effective for all homeless subgroups in achieving more positive
outcomes than other services, including other case management
models, remains to be seen. These
reviews have limitations: (1) they
focus solely on homeless individuals with severe mental illness,25---27 (2) they examine only
1 or 2 of the 4 models in use26,27
or do not distinguish between

different models and their individual effects,25 and (3) they consider
only certain outcomes.25,26 Morse
provides a more complete overview; however, he did not conduct
a systematic literature search and
failed to describe inclusion criteria
for studies. Furthermore, this review is dated and was not published in a peer-reviewed journal.19
Our primary goal was to examine the consistency of ndings
across various models of case
management and their applicability
in a variety of homeless subgroups
and settings through a complete
overview of the existing literature
on the effectiveness of the 4 case
management models. We categorized and evaluated all outcome
measures that were included in
randomized controlled trials and
quasi-experimental studies comparing these models to other services for the general homeless
population or specic homeless
subgroups.

METHODS
We conducted an electronic
systematic literature search for
peer-reviewed articles published
in English between January 1985
and June 2011 in the PsycINFO,
MEDLINE, Cochrane Library,
Embase, and CINAHL databases.

e14 | Systematic Review | Peer Reviewed | de Vet et al.

To identify study populations

that were predominantly homeless, we used the following keywords: homeless, homelessness,
and homeless people. We combined these keywords with the
following terms to search for the
4 case management models:
strengths-based, strengths
perspective, case management, intensive case management, assertive community
treatment, critical time intervention, outreach, outreach
programs, mental health,
mental illness, psychiatric,
and substance abuse (Appendix
A, Table A, available as a supplement to this article at http://www.
ajph.org). We used Web of Science
for a cited reference search.
After we conducted the search,
we removed duplicates, and 2 reviewers independently screened titles and abstracts of the retrieved
publications. We excluded reports
that did not match our inclusion
criteria, and 2 other reviewers
independently evaluated the
remaining publications. We resolved disagreements through
discussion among at least 3 reviewers to achieve consensus.

older. The recruitment strategy of

the study had to target a predominantly homeless population, as
evidenced by the description of
the target population, recruitment
setting, or selection criteria. For
the purpose of our review, we
dened homeless persons as
1. persons who lacked a xed,
regular, and adequate nighttime residence or resided at
night in a place not meant for
human habitation;
2. persons who were living in
a shelter;
3. persons who were exiting an
institution and resided in a
shelter or place not meant for
human habitation before institution entry;
4. persons who would imminently
lose their housing and lacked
the resources to obtain other
permanent housing;
5. unaccompanied youths or
homeless families with children
who experienced unstable
housing; and
6. persons who were eeing dangerous conditions in their current housing situation and
lacked the resources to obtain
other permanent housing.28

Selection Criteria
Participants in eligible study
samples were aged 18 years or

We imposed no restrictions
regarding other participant

American Journal of Public Health | October 2013, Vol 103, No. 10

SYSTEMATIC REVIEW

characteristics, such as being elderly, suffering from a mental illness, or having a military service
history.
The title or abstract had to
indicate that the study included
an intervention. In the full-text
article, at least 1 of the included
interventions had to be identied
as adhering to, or being based on,
1 of the 4 models of case management that we selected. Furthermore, the study had to be
designed as a randomized controlled trial or a before-and-after
study, incorporating a baseline
and at least 1 follow-up assessment of outcome variables,
comparing 2 or more groups that
received different interventions.
The article had to include
participant-level outcomes. Because our aim was to provide
a complete overview of all previously reported effects, we did
not limit our selection to preselected outcomes of interest or impose restrictions regarding the
services received by participants
in control groups or length of
follow-up.

Study Quality and Data

Extraction and Synthesis
Two reviewers critically appraised the selected publications
independently with criteria for
grading internal validity derived
from the US Preventive Services
Task Force Methods Work
Group,29 by which evidence is
classied as good, fair, or poor.
We derived cutoff points for
sample size, retention rate, and
overall rating from Hwang et al.30
and Altena et al.31 (Appendix B,
Tables B and C, available as a supplement to this article at http://
www.ajph.org).
Because we expected participants, settings, control group services, and outcome measures to
differ markedly between studies,

we could not conduct a metaanalysis. Instead, we focused on

narrative descriptions of the evidence, with the goal to examine
patterns across studies, provide
information about applicability
of results, and consider multiple
explanations for differential
ndings across studies. We
adapted the effect direction plot
by Thomson and Thomas to
prepare a visual summary of
effect direction for all reported
participant-level outcomes to
accompany the narrative
synthesis.32
We rst grouped the selected
publications according to case
management model and then
according to study sample. One
reviewer performed the data
extraction, which a second reviewer checked. In addition to
all participant-level outcomes, we
extracted details of the intervention
implementation, target population, recruitment setting, sample
size, study design, and length of
follow-up. We next tabulated
outcome data and grouped them
into 7 outcome domains derived
from the extracted outcome
measures, through a bottom-up
approach. The 7 outcome domains, 4 of which were further
divided into several outcome
categories, were
1. service use (services provided
by program staff and nonprogram inpatient, emergency, and
outpatient services),
2. housing,
3. health (physical and mental),
4. substance use (alcohol and
drugs),
5. societal participation (economic
participation---security, criminal
activity---legal problems, and
social behavior---support),
6. quality of life, and
7. cost (service expenses and
cost-effectiveness).

October 2013, Vol 103, No. 10 | American Journal of Public Health

We determined the direction of

effect impact (negative, positive,
none, or unclear) and the level of
statistical signicance (P .05) for
each extracted outcome measure
(Appendix C, Tables D---J, available
as a supplement to this article at
http://www.ajph.org). We further
synthesized the data to produce
a single indication of overall impact in each outcome category for
each publication, combining 2 or
more measures where more than
1 outcome was reported for any
outcome category. We used
several synthesis techniques, such
as tabulation, vote counting (as
a descriptive tool), and concept
mapping, in an iterative process as
recommended by Popay et al. to
conduct a narrative synthesis of
the research-based evidence from
the selected articles.33

RESULTS
The results of the systematic
search and selection process are
summarized in Figure 1. We retrieved 3721 publications. Our
review of titles and abstracts
identied 133 publications that
seemed to meet our criteria. Fulltext versions of 5 publications
could not be obtained, even by
requesting them from libraries
abroad or contacting the authors
directly. Further examination
of 128 full-text publications
revealed that 33 satised our
criteria for inclusion.34---66 Interrater agreement for publication selection was moderate (Cohen j =
0.49). Failing to include any of
the 4 case management models
as an experimental intervention
was the most common reason for
exclusion. Other publications had
to be excluded because participants were not predominantly
homeless or were younger than
18 years or because the studies
described lacked a randomized

or quasi-experimental design.
Initially, we intended to include
in our review strengths-based
case management (SBCM), a
model that emphasizes empowerment, self-direction, and the
relationship between client and
case manager,67,68 but none of
the publications that met our
selection criteria studied SBCM.
Therefore, we could only report
results of studies on SCM, ICM,
ACT, and CTI. Several publications reanalyzed previously
published data, and others contained results from more than 1
research site; the 33 publications
pertained to 21 unique study
samples.

Study Quality
Agreement between reviewers,
derived from the quality-rating
items for a subsample of 6 articles, was substantial (weighted
Cohens j = 0.64). Of the 33 included publications, we rated 17
as having good internal validity,
15 as fair, and 1 as poor (Appendix B, Table C). The publication with a poor rating omitted
important information about the
study design. We were unable
to determine whether comparable groups were assembled at
baseline, whether groups suffered from differential attrition,
whether valid and reliable measurement instruments were used
and applied equally among groups,
and whether an intention-to-treat
analysis was performed.42
Shortcomings encountered in
study designs rated as fair were
imprecisely dened interventions,37 assembly of unequal
groups,37,38 and loss to follow-up
of more than half of the sample
or failure to report follow-up
rates.44,54,66 Other limitations
were failing to maintain comparable groups during followup,37,43,54,60,62 failing to report

de Vet et al. | Peer Reviewed | Systematic Review | e15

SYSTEMATIC REVIEW

Outcome measures also varied

widely between studies. Frequently, different instruments
were used to measure the same
outcome (Appendix C, Tables D---J).
Table 3 presents the overall impact in each outcome category for
each publication, combining 2
or more measures where more
than 1 outcome was reported (a
visual interpretation of the synthesis
is available as a supplement to this
article at http://www.ajph.org).

Identification

Records identified through database searching (n = 17 293)

Records identified November 57, 2008
MEDLINE (n = 3907), PsycINFO (n = 5460), The Cochrane Library (n = 422), Embase
(n = 3250), CINAHL (n = 1705)
Records identified March 19, 2010
MEDLINE, PsycINFO, The Cochrane Library, Embase, and CINAHL (n = 1454)
Records identified June 67, 2011
MEDLINE, PsycINFO, The Cochrane Library, Embase, and CINAHL (n = 1095)

Records identified through cited

reference search
(n = 460)

Duplicates removed
(n = 14 032)

Screening

Total number of records identified

(n = 17 753)

Service Use

Eligibility

Records screened
(n = 3721)

Full-text publications assessed for eligibility

(n = 133)

Full-text publications excluded (n = 100)

Selected case management models not included
as experimental intervention (n = 67)
Participants not predominantly homeless (n =
13)
Not a peer-reviewed article (n = 11)
Full-text version not available (n = 5)
Lack of randomized or quasi-experimental
design (n = 3)
Participants younger than 18 years (n = 1)

Included

Publications included in qualitative synthesis

(n = 33)

Records excluded based

on title and/or abstract
(n = 3588)

Methodological quality of publications:

rating of good (n = 17), fair (n = 15), or poor
(n = 1)

FIGURE 1Summary of database search and study selection in review of literature on models of case
management for homeless adults, 19852011.
details of measurement procedures and to adequately blind
observers who assessed outcomes,35---39,41,48,66 and neglecting to perform an intention-to-treat
analysis and to control for key
confounders.35,39,43,45,52,62 We
considered methodological limitations that could increase the
risk of bias in our analysis.

Study Characteristics
Characteristics of included
studies are shown in Table 2.
Fourteen publications were issued

in 1999 (when the review by

Morse was published19) or later. Of
the 21 study samples, 20 were
recruited in the United States and
1 in the United Kingdom. The
sample sizes ranged from 80 to
722 participants; the total sample
size was 5618 participants.
Varying denitions of homeless
persons were employed across
studies, and various homeless
subgroups could be discerned:
literally homeless persons, persons at risk for homelessness,
homeless veterans, homeless

e16 | Systematic Review | Peer Reviewed | de Vet et al.

ex-prisoners, homeless substance

users, homeless persons with severe mental illness, and homeless
persons with co-occurring mental
and substance use disorders (dual
diagnoses). These subgroups represent the large variety of recruitment settings where potential participants were approached.
Because control group services
often consisted of the usual care
provided in a particular setting,
services received by participants
in control groups were also diverse (Table 2).

The 2 studies of SCM that

examined service utilization
detected few differences between SCM and the control
conditions.35,36 In a sample of
substance-dependent homeless
veterans, SCM participants received more support from program staff and other participants
and were better prepared for
program completion than participants in the control program.35 However, SCM did not
increase the use of other Veterans Affairs services, as had
been expected at the outset of
this study. With the exception
of reporting more substance
abuse treatment at the 3-month
follow-up, SCM participants
reported similar service use as
controls. 35 In line with these
ndings, a second study showed
that SCM for mentally ill people
who were homeless or marginally housed did not signicantly
affect participants needs for psychiatric and social care or reduce
the length of hospital stays.36
Two studies, both of which
examined samples of homeless
people with substance use problems, compared the services offered by ICM programs to usual
case management services. Participants recruited from a homeless
shelter who received ICM were
more satised than control

American Journal of Public Health | October 2013, Vol 103, No. 10

Recruitment Setting and

Location

October 2013, Vol 103, No. 10 | American Journal of Public Health

programs, Chicago, IL

were recently or

hospitals, Chicago, IL

a long-term, severe

users

Homeless substance

problems

clinic, New York, NY

Mobile medical outreach

Minneapolis, MN

Homeless people with

County detox center and
alcohol and other drug other agencies,

mental illness

Two state-operated mental

Detox center, Seattle, WA

center, Denver, CO

Homeless people with

homeless

detox services who were

High-frequency users of

substance abuse
problems

Homeless people with

Intensive case management

Substance abuse treatment

substance abuse

abuse programs who

imminently homeless

Short-term inpatient

Louisville, KY

Sobering-up station,

shelters, Boston, MA

agencies and homeless

Substance abuse treatment

Graduates of substance

problems

alcohol and other drug

Homeless men with

abusers

Homeless substance

homeless, Oxford, UK

practice clinic, and other

organizations for the

mental illness

for the homeless, general

functioning people with

severe, persistent

CBA

RCT

RCT

RCT

RCT

Q-RCT

CBA

RCT

Local night shelters, hostels RCT

community services)

program with referral to

Customary care (hospital

Comparison Condition

Customary aftercare

provided before the study

community

Access to aftercare in the

Intermediate case
management

case management)

based outpatient care and

Community services (office-

by social worker

referral to social worker

Intensive case management Services as usual and self-

Community-based intensive
case management

rehabilitation center

by psychiatric

Assertive case management

detox center

Intensive case management Standard treatment by the

services by the treatment

center

Intensive case management Treatment and rehabilitation

supported housing

2: case management with

1: Case management only,

services as intervention,
on request)

management (same

Proactive case management Self-initiated case

Case management services

services

Case management by social Continued assistance as

phase)

follow-up community

from VA hospital, Hines, IL

Case-managed residential

Intervention

care (residency phase and

RCT

Study
Design

psychiatric inpatient units

housed, poorly

Homeless or marginally

veterans

Homeless addicted male Substance abuse and

Standard case management

Case Management Model/

Target population

NR/NR

NR/NR

NR/NA

Ongoing/NA

4 mo/NA

8 mo/NA

Ongoing/ongoing

9 mo/NA

NR/NA

1 y/21 d

Duration, Intervention/
Comparison

NR/NR

1520 to 1/4050 to 1

10 to 1/NA

15 to 1/NA

15 to 2a/NA

NR/NA

NR/NR

30 to 1/NA

NR/NA

1025 to 1/NA

Client-to-Staff Ratio,
Intervention/Comparison

TABLE 2Sample Characteristics in Review of Research on the Effectiveness of Case Management Models for Homeless Adults

Orwin et al. (study 2)37

Orwin et al. (study 1)37

Marshall et al.36

Hultman et al.35

Conrad et al.,34

Study

128 in total

82/117

48/47

150/148

163/160

Continued

Rosenblum et al.42

Orwin et al. (study 3)37

Korr et al.41

Cox et al.40

Braucht et al.39

1: 96, 2: 136/187 Sosin et al.38

142/37

256/235

40/40

178/180

Baseline Sample
Size, Intervention/
Comparison

SYSTEMATIC REVIEW

de Vet et al. | Peer Reviewed | Systematic Review | e17

RCT

services by residential

e18 | Systematic Review | Peer Reviewed | de Vet et al.

Francisco and San Diego,

CA; New Orleans, LA; and

Cleveland, OH

a substance abuse

disorder, dual disorder,

or psychiatric disorder

VA medical centers, San

RCT

community treatment only

by community mental

by homeless persons), St
Louis, MO

Homeless veterans with

agencies, 2: assertive

street locations frequented

disorder

special access to housing

subsidies

community treatment with

modified assertive

VA case managers, 2:

community treatment by

1: Modified assertive

health agencies

community mental health

psychiatric hospitals,

community treatment by

1: Integrated assertive

and substance use

RCT

treatment

(emergency shelters,

Variety of settings

Louis, MO

severe mental illness

Homeless people with

a severe mental illness

Assertive community

workers

Louis, MO

Local emergency shelters, St RCT

treatment with community

psychiatric hospital, St

Homeless people with

treatment only, 2:
assertive community

inpatient units of the

public acute care

1: Assertive community

serious mental illness

RCT

Emergency rooms and

services), Buffalo, NY

housing assistance

kitchens, crisis and

management)

management)

services (broker case

Standard VA homeless

community services)

assistance to access

Standard care (linkage

services)

assistance with social

outpatient therapy,
medication, and

NR/short term

NR/NA

25 to 1/NR

NR/NA

Morse et al.54

et al.,52 Morse et al.,53

Calsyn et al.,51 Fletcher

Continued

Rosenheck et al.56

1: 90, 2: 182/188 Cheng et al.,55

1: 61, 2: 65/65

et al.50

treatment (office-based

Calsyn et al. (study

Wolff et al.49

2),47 Morse et al.,48

et al. (study 2),46

McBride et al. (study

Burger et al.,45 Calsyn

Toro et al.44

(study 1),47 Morse

52/1: 62, 2: 64

165 in total

101/101

Stahler et al.43

workers), 2: outpatient

10 to 1/1: 40 to 1, 2: NA

10 to 1/85 to 1

NR/NA

302

200/1: 220, 2:

1),46 McBride et al.

Ongoing/1: NR, 2: NA

Ongoing/NR

8 mo/NA

nonspecific

15 to 1/1: NA, 2: 5075 to 1

(assistance by social

1: Daytime drop-in center

Broker case management

Intensive case management Free to seek services in the

community

Homeless people with

treatment

Assertive community

Homeless people

care shelter services (case

management

Shelter-based intensive case 1: Integrated comprehensive 9 mo/1: 6 mo, 2:

alcohol or drug use

Local human service

agencies (shelters, soup

RCT
treatment facility, 2: usual

Philadelphia, PA

Mens homeless shelter,

and a problem with

stable mental health

Homeless men with

TABLE 2Continued

SYSTEMATIC REVIEW

American Journal of Public Health | October 2013, Vol 103, No. 10

mental health centers,

Connecticut

substance use disorder,

people, Baltimore, MD

Jail system of a large US

with dual diagnoses

Homeless and seriously

October 2013, Vol 103, No. 10 | American Journal of Public Health

to outpatient services

and San Diego, CA

Richmond and Salem, VA;

Lyons, NJ; Montrose, NY;

Usual discharge planning

to community agencies)

Usual services only (referral

community mental health

centers

referral to aftercare by

forensic case managers, 2:

management by individual

1: Intensive case

services)

Usual community services

(generic case management

case management

Integrated standard clinical

services by inpatient unit

staff and standard referral

Critical time intervention

Critical time intervention

forensic case managers

treatment by team of

Assertive community

Assertive community
treatment

community treatment

Integrated assertive

medical centers, Chicago

and Hines, IL; Houston, TX;

HCT

RCT

RCT

RCT

RCT

6 mo/NA

9 mo/NA

1 y/1: NR, 2: NA

Ongoing/NR

NR/NR

15 to 1/NA

NR/NA

NR/NR

1012 to 1/NR

1015 to 1/25 to 1

206/278

48/48

60/1: 60, 2: 80

77/75

99/99

Kasprow et al.66

Susser et al.65

Lennon et al.,64

et al.,62 Jones et al., 63

Herman et al.,61 Jones

Solomon et al.60

Lehman et al.,58
Lehman et al.59

Essock et al.57

Note. CBA = controlled before-and-after study; HCT = historically controlled trial; NA = not applicable; NR = not reported; Q-RCT = quasi-randomized controlled trial; RCT = randomized controlled trial; VA = Veterans Affairs.
a
This program employed a dyad structure, with pairs of case managers sharing caseloads.

homeless veterans with

serious mental illness

Inpatient units of VA

York, NY

shelter

Recently or imminently

in a mens shelter, New

On-site psychiatry program

people leaving a mens

Severely mental ill

Critical time intervention

being released from jail

urban center

agencies for homeless

mental illness, most

mentally ill people

Inner-city psychiatric
hospitals and community

Homeless people with

severe, persistent

skills

poor independent living

high service use, and

outpatient community

severe mental illness,

Two state-operated

housed people with

Homeless or unstably

TABLE 2Continued

SYSTEMATIC REVIEW

participants, although a minority

(29%) of the ICM participants
completed the program.43 In the
other study, participants recruited
at a medical van who were
assigned to the ICM group had
signicantly more contacts with
the medical vans case manager
than did control participants,
who had the opportunity for
self-referral to the same case
manager.42 Although these 2
studies found that program services signicantly differed between conditions, ndings from
3 other studies on the impact of
ICM on nonprogram service utilization were mixed.
The number of days spent in
psychiatric hospitals by homeless
mentally ill people did not differ
between ICM and control participants.41 Among homeless substance users, ICM did not have
a signicant differential effect on
the number of days spent in
residential treatment facilities or
the number of in- and outpatient
services received.39 We found
some evidence, however, that
ICM was more effective than
standard detoxication treatment
in reducing subsequent detox
admissions.40
Six studies, as reported in 8
articles, compared the services
received by ACT and control participants.48---50,52---54,56,60 These
studies indicated that, for several
different homeless subpopulations,
ACT increased contacts between
participants and case managers or
other program staff,48---50,53,54,56,60
enhanced the level of assistance
directly provided by program
staff,48,53,56 and improved participant satisfaction.48---50,52,53
One article, which reported
ndings from 2 studies with severely mentally ill homeless participants, showed that participants in the ACT programs had
relatively larger professional

de Vet et al. | Peer Reviewed | Systematic Review | e19

Fair

Fair

Marshall et al.36

Orwin et al.

e20 | Systematic Review | Peer Reviewed | de Vet et al.

Fair

Fair

Korr et al.41

Orwin et al.

Fair

Good

Good

Good

Calsyn et al.

McBride et al.

Good

Fair

Good

Fair

Good

Good

Fletcher et al.52

Morse et al.53

Morse et al.54

Cheng et al.55

Rosenheck

Good

Good

Good

Essock et al.57

Lehman et al.58

Lehman et al.59

et al.56

Good

Morse et al.50

Calsyn et al.51

(study 1)47

(study 1)46

Fair

Morse et al.48

Wolff et al.49

(study 2)47

McBride et al.

Good

Good

Calsyn et al.

(study 2)46

Fair

Burger et al.45

treatment

community

Assertive

Fair

Stahler et al.43

Toro et al.44

et al.42

Rosenblum

Poor

Good

(study 3)37

Fair

Cox et al.40

Fair

Braucht et al.39

management

Intensive case

Sosin et al.38

(study 2)37

Orwin et al.

Fair

Fair

(study 1)37

Good

Hultman et al.35

Quality
rating

Conrad et al.34

management

Standard case

Intervention/
Study

Mixedb15

Mixed5

Positive3

Positive

Positive2

Positive2

Mixed10

Positive

Positive

Inpatient
Nonprogram

Service use

Mixed10

Positive

Positive2

Positive2

Mixed3

Positive

Emergency
Nonprogram

No difference5 Mixed3

Mixed3

Mixeda

No difference3

No differencea

Positive

No difference2 No difference5

No differencea No difference

No difference20 Mixed8

Program

General
Nonprogram

Mixed4

Mixed3

No difference

Mental

No differencea

No difference

Health

No difference2 Mixed2

Positive

Physical

Positive

Positive

Mixeda2

Mixed2

No difference

No difference

Positive

Positive2

Mixed4

Mixeda
Mixed

No difference6 No difference

No difference4 No difference

Positive

Positive

Positive

Positivea

Positive

No difference

No difference2

No difference

No difference

Positive

General

Positive

No differencea Positivea

No difference2

No difference

No difference

No difference

No difference

No difference2

Positive

Mixed6

Mixed2

No differencea Mixeda4

No difference

No difference2 Mixed2

No difference2 No difference2 No difference

Positive

No difference2 No difference2 No difference2

Positive2

No difference2

Mixeda

Housing

No difference7 No difference2

No difference

Outpatient
Nonprogram

TABLE 3Impact of Case Management Models on Outcomes for Homeless Adults

Mixed2

Mixed

Drugs

No difference3

No difference

Negative

Mixeda2

Positive

No difference

No difference

No difference

No difference3

No difference

No difference

No difference

Mixed3

No difference

No differencea2

No difference2

Positive

Mixed3

Mixed3

No difference2

Mixed3

Mixed3

Mixeda2

Social

No difference3

No difference

No difference

Mixeda

No difference3 No difference3

No difference6

No difference9

No difference10

No differencea3

No difference2 No difference

No difference2 No difference2

No difference

Criminal

Societal participation
Economic

No differencea No difference2

General

No differencea2 No differencea

No difference2 No difference2

No difference3 No difference3

No difference2 No difference2

No difference

No difference2 No difference2

No differencea

Mixed3

Mixed2

Mixed7

No difference2 Mixed2

No difference2 No difference2

Mixed2

Positivea

Alcohol

Substance use

Mixed7

No differencea

No difference6

Negative

Mixed

No differencea

Quality of life

Mixed13

No difference

Cost-Effect

Continued

Cost

No difference18

Mixed4

Mixedb7

Service

SYSTEMATIC REVIEW

American Journal of Public Health | October 2013, Vol 103, No. 10

Fair

Good

Good

Good

Fair

Jones et al.63

Lennon et al.64

Susser et al.65

Kasprow et al.66

Note. Mixed = mixed or conflicting study findings; negative = intervention had negative impact on outcome; no difference = intervention and comparisons outcomes were the same; positive = intevention had a postive impact on outcome. All
differences between control and intervention group at follow-up were significant at P .05 (unless otherwise indicated). Synthesis of multiple outcomes within same outcome category: where multiple outcomes all reported effects in the
same direction, we reported this effect direction. Where direction of effect varied across multiple outcomes, we reported the majority effect direction if 70% of outcomes reported a similar direction. If less than 70% of outcomes reported
a consistent direction of effect, we reported the effect direction as mixed. Where availability of statistics or data varied, we considered effects as statistically significant if statistical significance was available for more than 60% of the
outcomes. Number of outcomes within each category synthesis was 1 unless indicated in subscript beside effect direction.
a
Difference in change between control and intervention group.
b
No statisticsdata reported.

No difference2
Mixed6

Positivea

Mixedb3
Good

Jones et al.62

intervention

Herman et al.61

Mixed3
Solomon et al.60 Fair

Critical time

TABLE 3Continued

No differenceb Mixed2

Positivea

Positive3

No differenceb3 Mixedb6

Mixedb3

Mixed3

Positivea

Positive2

Positive2

No difference4

Mixedb2

No difference

No difference21

Mixed6

SYSTEMATIC REVIEW

October 2013, Vol 103, No. 10 | American Journal of Public Health

networks.46 In 1 of these same

samples, Morse et al. found that
ACT participants also had more
contacts with service agencies
than did control participants.50
In a reexamination of the other
sample, however, Wolff et al.
found no signicant differential
effects with regard to in- or outpatient services for these mentally ill homeless participants.49
This reanalysis may have lacked
sufcient power or may have
been biased by differential attrition, because service utilization
data were available for approximately half of the original sample.
For participants with dual
diagnoses, we found evidence that
ACT is effective in shortening the
length of psychiatric hospital
stays57---59 and reducing the
number of emergency room visits
for mental health problems.58,59
ACT was not found to signicantly reduce other inpatient
service use by these participants,
such as inpatient medical care,58,59
residential substance abuse treatment,58,59 or mental health rehabilitation.59 Two articles on the
same study reported that ACT
participants with dual diagnoses
visited outpatient mental health
services and substance abuse
treatment more often than participants receiving generic case
management services.58,59
Among substance-using homeless veterans, however, ACT did
not have a differential effect on
outpatient service use.56
None of the articles examined
the differences between program
services provided by CTI and
control conditions. Preliminary
results indicated that CTI increased use of nonprogram outpatient services.62 In another
study, CTI reduced the length of
hospital and other institutional
stays for mentally ill homeless
veterans.66

Housing
Of 5 studies examining the impact of SCM on housing stability,
3, all reporting on homeless substance users, showed statistically
signicant effects.34,37,38 The 2
studies that did not nd a positive
impact of SCM on housing outcomes differed in several important ways. In 1 study, high-risk
participants in the sample of
homeless substance users were
all assigned to the SCM condition,
which as implemented did not
differ in type or intensity of services from the control condition.37
In the other, the sample consisted
of mentally ill people instead of
substance users, and sample size
of 80 may have provided insufcient power to reveal a signicant
difference between groups in the
housing variables.36
Seven studies of ICM produced
mixed results on housing outcomes. Of the 5 studies investigating the effects of ICM on
homelessness or residential stability in substance-abusing populations,37,39,40,42,43 1 reported
a signicantly better result for
ICM than for the control condition.40 These mostly nonsignicant ndings could have been
attenuated by treatment nonadherence and lack of differential
service utilization between groups.
For example, 71% of participants
assigned to shelter-based ICM
services for substance-using
homeless men did not complete
the program.43
The 2 studies of ICM that did
not examine homeless substance
users showed a positive impact
on housing. In a study with severely mentally ill participants,
ICM signicantly improved housing stability.41 In a more heterogeneous sample of homeless persons,
participants receiving ICM experienced better living conditions

de Vet et al. | Peer Reviewed | Systematic Review | e21

SYSTEMATIC REVIEW

during follow-up than did control

participants.44
Most articles examining the
effect of ACT on housing
outcomes found positive effects.47,48,50,52---54,57,58 Homeless
persons with severe mental illness who received ACT spent
fewer days homeless or more
days in stable housing than did
participants who received
drop-in center services, ofcebased outpatient treatment, or
less proactive case management.47,48,50 For homeless participants with dual diagnoses,
ACT programs also improved
housing stability more than SCM
and other forms of linkage assistance.52---54,57,58 As reported in 2
articles, 1 study with homeless
veterans with substance abuse
disorders did not nd a signicant positive effect of ACT on
housing. For this sample, ACT
did not have a signicant impact
on any of the housing-related outcome measures, unless participants were also supplied with
special access to subsidized housing (Section 8 vouchers).55,56
However, the model integrity of
this ACT program was debatable
because the case managers had
relatively high caseloads of 25
clients.
Multiple reports examined
CTI housing outcomes in 2 unique
samples.62---66 For mentally ill
men leaving a homeless shelter,
adding CTI to community services for 9 months was effective
in decreasing homeless nights.62---65
Interestingly, the difference between groups became more pronounced after the time-limited
intervention had ended.65 In
a study with homeless veterans
who were leaving inpatient care,
CTI signicantly increased days
housed, although the CTI and
control groups did not differ in
nights spent homeless.66

Physical and Mental Health

Two articles examined the
impact of 3 SCM programs on
physical health problems.34,37 In
1 study, the SCM program for
homeless substance users, provided in a residential setting,
helped to lessen the severity of
participants medical problems.34
Two other studies employed
similar samples and used the
same measurement instrument
but did not detect any effects,
although results might have been
weakened by attrition bias and
program nonadherence.37 The 4
studies that addressed mental
health problems did not nd
a signicant positive effect of
SCM.34,36,37
Homeless substance users did
not benet from ICM in their
physical or mental health in 4
studies.37,39,42,43 In a heterogeneous group of homeless persons,
ICM had a positive impact on
interviewer ratings of psychiatric
symptom severity.44 Although
participants ratings of symptom
severity did not differ between
groups, ICM participants reported
fewer stressful life events, which
have been well established as
a predictor of several mental
disorders, particularly depression.69---71
Because the 3 articles that
discussed the impact of ACT on
participants physical health generally did not report differential
effects, little evidence exists that
ACT affects this outcome.55,56,58
Two of 6 studies that assessed
mental health impacts found statistically signicant reductions
in psychiatric symptoms.48,58 In
a mentally ill sample, Morse et al.
found that interviewer ratings
for some symptoms were lower
for the ACT group, although their
unmasked interviewers may
have introduced bias.48 Another

e22 | Systematic Review | Peer Reviewed | de Vet et al.

study found that homeless participants with dual diagnoses

reported fewer symptoms if they
had received ACT.58
A signicant effect of CTI on
the reduction of psychiatric
symptoms was demonstrated in
both studies with mental health
problems as an outcome.61,66 No
article reported inclusion of
a physical health measure.

Substance Use
Four studies of SCM, whose
participants were homeless people
with substance abuse problems,
assessed substance use outcomes,
as reported in 3 articles.34,37,38 All
but 1 found differential effects,
suggesting that SCM was signicantly more effective than referral
to community services in reducing
alcohol and drug use among
homeless substance users.34,37,38
In the 1 study that did not replicate these results, all participants
at high risk for relapse were
assigned to the SCM group. Moreover, the services received hardly
differed between groups. Therefore, it is not surprising that SCM
participants did not reduce their
substance use more than control
participants.37
Four of 6 studies of the effect
of ICM on alcohol or drug use did
not show a positive impact.37,39,42,44
One study provided some evidence that ICM decreased days
drinking and the severity of alcohol problems for homeless
substance users.40 This was conrmed by a per-protocol analysis
of a second study with a similar
sample: program completers
reported less alcohol use than did
control participants.43 However,
2 other studies failed to replicate
these ndings,39,44 and another
studys results signicantly favored the control condition.37
These nonsignicant and negative results could have been

biased by methodological limitations, such as high rate of attrition44 and lack of differentiation
in services received.37,39
Five studies, which produced
8 articles with alcohol and drug
use outcomes, concluded that
ACT did not signicantly affect
substance use or related problems.48,50,52---57 One study on CTI
looked at substance use variables. 66 In a sample of mentally
ill homeless veterans, those offered CTI improved more with
regard to alcohol and drug use
than participants who received
usual services. Furthermore,
participants in the CTI group
spent less money on these substances.66

Societal Participation and

Quality of Life
Three articles with ndings
from 4 studies on SCM included
measures related to societal participation.34,36,37 Two studies
found that mentally ill or
substance-using homeless participants who received SCM did
not spend more days in employment.36,37 Homeless substance
users receiving SCM also did not
experience more economic security,37 although they generally
reported fewer problems that interfered with employment.34,37
One study looked at the impact
of SCM on the severity of legal
problems experienced by homeless substance users and did not
nd a differential effect.34 In
a sample of mentally ill homeless
persons, interviewers observed
less deviant behavior among SCM
than among control participants,
although participants perceptions
of their social behavior and interviewer ratings of general functioning did not differ between
groups.36
We found very little evidence
that ICM improved economic

American Journal of Public Health | October 2013, Vol 103, No. 10

SYSTEMATIC REVIEW

participation or security,37,39,40,43,44
reduced criminal activity or legal
problems,39,43 or promoted social behavior or support.39,43,44
Two studies indicated that ICM
could help homeless substance
users to access sources of public
assistance.40,42 A study with
a heterogeneous sample of
homeless people, however, did
not yield the same result.44
Similarly, ACT did not seem to
have any impact on economic participation or security.48---50,53,55,56
Of 5 studies exploring the effect
of ACT on measures of criminal
activity or legal problems,51,56-- 58,60
1 showed a signicant differential
effect: for participants with dual
diagnoses, ACT signicantly decreased the likelihood of being
incarcerated.57 In addition, ACT
did not affect variables related to
social support, except for an
effect on perceived material support at 1 research site.46 No other
differences were found between
ACT and control groups in the
size or quality of participants
social network for 2 samples of
mentally ill and 2 samples of
homeless people with dual
diagnoses.46,50,55,56
Studies of CTI found no differential effect regarding days in
employment66 or income.63,66
One study found that CTI participants spent fewer days in jail
than control participants. The
article, however, did not report
any statistics.62 None of the
studies included measures of social behavior or support as outcomes.
Few studies considered quality
of life as an outcome. One study,
on the effectiveness of ACT for
homeless persons with dual diagnoses, found a signicant improvement.58 ACT participants
were generally more satised with
life than those receiving SCM services at a 6-month follow-up. Over

longer periods of follow-up, however, no evidence was found

for an effect of ACT on this outcome in samples of dually diagnosed homeless persons57,58 or
substance-abusing homeless veterans.55,56 Similarly, SCM did not
seem to improve the quality of life
of homeless and marginally housed
people with mental disorders
relative to usual community care.
In a study with homeless substance users, general life satisfaction was higher among control
participants, who received usual
services, than among participants
who received ICM.39

Service Costs and CostEffectiveness

No study examined the costs
associated with SCM or ICM. In
line with the differential effects
of ACT on service utilization,
studies conrmed that costs for
outpatient services, including
case management services, were
higher for ACT than for standard
services offered by psychiatric
hospitals and agencies serving
homeless persons.49,53,56,59
Costs for inpatient services,
however, were lower, which led
Lehman et al.59 and Wolff et al.49
to conclude that their ACT programs were not more expensive
than usual services and achieved
better results.
Similarly, the pattern of service use associated with CTI was
reected in its cost. Acute mental
health costs, which include
charges for inpatient and emergency services, were lower for
CTI than for standard shelter
services, although this difference
was not signicant.63 The only
signicant differential effect was
a substantial reduction in shelter
costs among CTI participants.63
Jones et al. demonstrated that the
cost of resources used by CTI
participants did not differ from

October 2013, Vol 103, No. 10 | American Journal of Public Health

the costs for usual care participants

and that the costs for providing CTI
were compensated for by longterm improvements in housing
stability.63

DISCUSSION
Our systematic review is the
rst to our knowledge to provide
a comprehensive overview of
the evidence provided by randomized controlled trials and
quasi-experimental studies for
the effectiveness of 4 models of
case management in homeless
populations. Because the case
management models perform
the same functions, they are not
mutually exclusive.20 Many
studies we reviewed did not ascertain whether services were
delivered in accordance with the
criteria of the model. We categorized the studies by model
according to denitions provided in the articles; these categories were correct only to the
extent that the studies reported
accurate information about the
models.
Except for 1 study conducted
in the United Kingdom with severely mentally ill people, all
studies concerned with SCM
recruited homeless substance
users as participants. Although
we found little evidence for a differential effect on service utilization, the ndings provided some
evidence that SCM is effective for
this homeless subpopulation in
improving housing stability, reducing substance use problems, and
removing employment barriers.
For the mentally ill sample, however, few of these results were
replicated. Thus, SCM seemed to
be more benecial than usual care
for substance-using homeless
persons.
Five out of 7 studies that
assessed the effect of ICM also

focused on homeless substance

users. For this group, ndings
were nonsignicant or mixed in
all outcome categories except for
access to public assistance. Study
quality ratings and service utilization data suggested that these
largely nonsignicant ndings
could be the result of treatment
nonadherence and lack of
between-group differentiation
in the services received. The 2
other ICM studies provided some
evidence for a positive effect of
ICM on housing outcomes for
severely mentally ill homeless
persons and the general homeless population. However, more
research is needed before any
conclusions can be drawn about
the consistency of these ndings.
The samples in studies of
ACT consisted of homeless
persons with dual diagnoses,
severely mentally ill persons,
substance-using veterans, and
mentally ill ex-prisoners. Results
indicated that ACT improved the
housing stability of severely mentally ill as well as dually diagnosed
homeless participants more than
less proactive case management
models. Outcomes related to housing were not included in the study
with mentally ill ex-prisoners and
did not improve in the sample of
substance-using veterans; however,
this could be attributable to
a lack of model delity in this
study. For all subpopulations,
ndings in the other outcome
categories were largely nonsignicant or inconsistent. Although ACT appeared to inuence patterns of mental health
service use, most studies did not
show a differential effect of
ACT on psychopathology or
other mental health outcomes.
Nevertheless, the improvements
in housing stability and reductions in inpatient and emergency
mental health service use seemed

de Vet et al. | Peer Reviewed | Systematic Review | e23

SYSTEMATIC REVIEW

to be sufcient to compensate for

the higher costs associated with
ACT.
Our ndings are consistent
with the 4 previous reviews of
the literature on this topic. All
these reviews found ACT superior to other services, including
other models of case management, in helping severely mentally ill homeless persons to
achieve housing stability.19,25---27
Contrary to our ndings, however,
Coldwell and Bender also concluded that ACT participants
demonstrated greater improvement in psychiatric symptom
severity.26
CTI was examined in 2 samples of severely mentally ill
homeless persons, 1 group leaving a homeless shelter and the
other leaving inpatient care for
veterans. For both groups, CTI
was signicantly better than
usual services in supporting
housing stability and reducing
psychiatric symptoms and substance use. The improved level of
housing stability experienced by
these severely mentally ill participants appeared to be linked to
the positive impact of CTI on the
length of hospital, shelter, and
other institutional stays. CTI
achieved better long-term results
than usual care with similar associated costs. CTI was the least
researched model in our review,
so consistent results from further
studies are needed. Nevertheless,
results from these 2 studies were
very promising.
Across the 4 different models,
case management generally
seemed to have a positive impact
on housing stability and patterns
of service use. Findings about
substance use outcomes were
mixed, and effects on variables
measuring health, societal participation, and quality of life were
largely nonsignicant.

Limitations
Because of great variability between studies, comparisons of research ndings could only be undertaken with great caution. In
addition, caution was warranted
by heavy reliance on participants
self-reports. Self-report data can
give rise to over- or underreporting of treatment effects and a distortion of the differences between
experimental and control
groups.72---74
We excluded reports that were
not published in English between
1985 and 2011, possibly giving
rise to selection bias. We also
excluded studies that did not include a control group, such as
descriptive reports and studies
with a pretest---posttest design. The
qualitative information that we
may have omitted as a result might
have elucidated the quantitative
data provided by randomized
and quasi-experimental research.

Generalizing Research
Findings
Our review showed that case
management has produced favorable effects in homeless populations, but also revealed gaps in the
evidence. Because the evidence
for the effectiveness of case management has been collected in the
context of specic times, locations,
and service settings, this research
cannot easily be extrapolated.
Most of the trials in our review
that assessed the effectiveness of
case management were conducted
in a particular time frame as part
of multisite demonstration programs in the United States that
addressed the specic problems
of homelessness of that time and
focused on individuals with
chronic or severe mental illness,
substance abuse problems, or dual
diagnoses.75,76 Although the
prevalence of mental illness and
substance use among homeless

e24 | Systematic Review | Peer Reviewed | de Vet et al.

people is still high, many are not

mentally ill.11 More evidence is
needed to establish which model
is most suitable and cost-effective
for homeless people who are not
mentally ill and are not substance
users but who often have fewer
or other support needs.
Similarly, we found examples
of limited generalizability across
countries. All but 1 of the studies
we reviewed were conducted in
the United States. The only European study, from the United
Kingdom, could not replicate
many of the ndings from earlier
studies. Because other countries
have marked differences in social
welfare systems, housing and labor
markets, and health care systems, in
addition to differences in the nature
of their homeless populations,10,77
it is highly likely that evidencebased practices from the United
States will not produce the same
results in European countries. In
a review of the research literatures
in the United States and other developed nations, Toro also notes
that systematic research evaluating
interventions for homeless people
is virtually nonexistent in Europe.10

Implications for Future

Research and Practice
To properly inform policymakers in the European Union,
experimental trials should be
conducted among different
homeless groups in a variety of
service settings and countries.
These studies should be carefully
designed. They should aim for
more uniformity in outcomes examined and for more standardization of measurement instruments. Moreover, several important
outcomes have received insufcient study. Few publications in
our review included outcomes
related to quality of life, societal
participation, physical health, or
community integration.

Future studies should summarize or refer to key components

of the intervention being studied
and present results of model delity assessment.19,27 Inclusion of
model delity in the study design
is vital to explore relationships
between case management
models, homeless subgroups,
service settings, and outcomes.
Rather than comparing competing models, it may be more
fruitful to attempt to predict
which well-dened components
of a given case management
model will facilitate favorable
outcomes for certain homeless
subpopulations and what approach will be most cost-effective.78
Our results suggest that practitioners could employ case management to assist homeless persons with improving their housing
stability and changing their service
use patterns. We found little evidence for the effectiveness of ICM,
but this could very well be attributable to factors not related to this
model. SCM seems to improve
housing stability, reduce substance
use problems, and remove employment barriers for homeless
substance users more than referral
to community services. Compared
with SCM and other case management services, ACT has consistently produced positive effects
on housing stability and has been
found to be cost-effective. However, this model seems to be suitable mainly for mentally ill or
dually diagnosed homeless persons with multiple and complex
needs.23 CTI has also produced
promising results and seems to be
more applicable for a variety of
settings and populations because
of its practical and time-limited
nature.24 Only when the evidence
gaps have been addressed can we
establish which case management
models or which specic components of these models are most

American Journal of Public Health | October 2013, Vol 103, No. 10

SYSTEMATIC REVIEW

suitable to accompany housing, as

part of a rapid-rehousing approach
to homelessness, for specic homeless subgroups. j

About the Authors

At the time of the study, Rene de Vet,
Maurice J. A. van Luijtelaar, Sonja N.
Brilleslijper-Kater, Marille D. Beijersbergen,
and Judith R. L. M. Wolf were with the
Department of Primary and Community
Care, Radboud University Nijmegen
Medical Centre, Netherlands. Sonja N.
Brilleslijper-Kater is with the Child Abuse
and Neglect Team, Academic Medical
Center, Amsterdam, Netherlands. Wouter
Vanderplasschen is with the Department of
Orthopedagogics, Ghent University,
Belgium.
Correspondence should be sent to Judith
R. L. M. Wolf, PhD, Radboud University
Nijmegen Medical Centre, Department of
Primary and Community Care, PO Box
9101, 6500 HB Nijmegen, Netherlands
(e-mail: j.wolf@elg.umcn.nl). Reprints can be
ordered at http://www.ajph.org by clicking the
Reprints link.
This article was accepted May 23,
2013.

Contributors
R. de Vet led the writing and assisted
with the study. M. J. A. van Luijtelaar
conducted the search and assisted
with the study and writing. S. N.
Brilleslijper-Kater assisted with the study.
J. R. L. M. Wolf originated, designed, and
supervised the study and obtained
funding, assisted by M. D. Beijersbergen.
All authors conceptualized ideas,
interpreted ndings, and reviewed drafts
of the article.

Acknowledgments
This study was funded in part by the
Netherlands Organization for Health Research and Development.
We thank the authors who assisted us
with obtaining full versions of publications unavailable in the Netherlands. We
also acknowledge the contribution of
Lenny Schouten, research assistant, Department of Primary and Community
Care, Radboud University Nijmegen
Medical Centre, to the study selection
and data extraction process.
Note. The funding organization had
no role in the design and conduct of the
study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the article.

Human Participant Protection

No protocol approval was required because the data were obtained from secondary sources.

References
1. Toro PA, Tompsett CJ, Lombardo S,
et al. Homelessness in Europe and the
United States: a comparison of prevalence
and public opinion. J Soc Issues. 2007;63
(3):505---524.
2. Cortes A, Leopold J, Rothschild L,
Buron L, Khadduri J, Culhane DP. The
2010 annual homeless assessment report
to Congress. US Department of Housing
and Urban Development. 2011. Available
at: http://www.hudhre.info/documents/
2010HomelessAssessmentReport.pdf.
Accessed August 22, 2012.
3. European Commission and European
Federation of National Organisations
Working with the Homeless. European
Consensus Conference on Homelessness:
policy recommendations of the jury. 2011.
Available at: http://www.feantsa.org/
les/freshstart/Consensus_Conference/
Outcomes/2011_02_16_FINAL_Consensus_
Conference_Jury_Recommendations_EN.pdf.
Accessed August 22, 2012.
4. Lehman AF, Kernan E, DeForge BR,
Dixon L. Effects of homelessness on the
quality of life of persons with severe
mental illness. Psychiatr Serv. 1995;46
(9):922---926.
5. Hubley AM, Russell LB, Palepu A,
Hwang SW. Subjective quality of life
among individuals who are homeless:
a review of current knowledge. Soc Indic
Res. Epub ahead of print February 3,
2012.
6. Lam JA, Rosenheck RA. Correlates of
improvement in quality of life among
homeless persons with serious mental
illness. Psychiatr Serv. 2000;51(1):116--118.
7. Wolf J, Burnam A, Koegel P, Sullivan
G, Morton S. Changes in subjective
quality of life among homeless adults who
obtain housing: a prospective examination. Soc Psychiatry Psychiatr Epidemiol.
2001;36(8):391---398.

clients treated by the federally funded

(US) Health Care for the Homeless Programs. Health Soc Care Community.
2009;17(1):18---26.
13. Sun S, Irestig R, Burstrom B, Beijer
U, Burstrom K. Health-related quality of
life (EQ-5D) among homeless persons
compared to a general population sample
in Stockholm County, 2006. Scand J
Public Health. 2012;40(2):115---125.
14. Baggett TP, OConnell JJ, Singer DE,
Rigotti NA. The unmet health care needs
of homeless adults: a national study. Am J
Public Health. 2010;100(7):1326---1333.
15. Barrett B, Fogel SJ, Garrett J, Young
MS. Assessing health care needs among
street homeless and transitionally housed
adults. J Soc Serv Res. 2011;37(3):338-- 350.
16. Berg S. The HEARTH Act. Cityscape.
2013;15(1):317---324.
17. Pleace N. Housing rst. European
Federation of National Organisations
Working with the Homeless. 2012.
Available at: http://www.feantsa.org/
les/freshstart/Policy%20documents/
2012_04_27_FINAL_EN.pdf. Accessed
September 18, 2012.
18. Shinn M, Greer AL. The European
Consensus Conference on Homelessness--kudos, and some cautions, to Europe. Eur
J Homelessness. 2011;5(2):183---190.
19. Morse G. A review of case management for people who are homeless: implications for practice, policy, and research. In: Fosburg LB, Dennis DO, eds.
Practical Lessons: The 1998 National
Symposium on Homeless Research. Washington, DC: US Department of Housing and
Urban Development; 1999:7-1---7-34.
20. Vanderplasschen W, Rapp RC, Wolf
JR, Broekaert E. The development and
implementation of case management for
substance use disorders in North America
and Europe. Psychiatr Serv. 2004;55
(8):913---922.

8. Shlay AB, Rossi PH. Social science

research and contemporary studies of
homelessness. Annu Rev Sociol.
1992;18:129---160.

21. Vanderplasschen W, Wolf J, Rapp

RC, Broekaert E. Effectiveness of different
models of case management for substanceabusing populations. J Psychoactive Drugs.
2007;39(1):81---95.

9. Philippot P, Lecocq C, Sempoux F,

Nachtergael H, Galand B. Psychological
research on homelessness in Western
Europe: a review from 1970 to 2001.
J Soc Issues. 2007;63(3):483---503.

22. Rog DJ, Andranovich G, Rosenblum

S. Intensive Case Management for Persons
Who Are Homeless and Mentally Ill. Washington, DC: COSMOS Corp; 1987.

11. Fazel S, Khosla V, Doll H, Geddes J.

The prevalence of mental disorders
among the homeless in Western countries: systematic review and metaregression analysis. PLoS Med. 2008;5
(12):e225.

23. Stein LI, Test MA. Alternative to

mental hospital treatment, I: conceptual
model, treatment program, and clinical
evaluation. Arch Gen Psychiatry. 1980;37
(4):392---397.
24. Herman DB, Mandiberg JM. Critical
time intervention: model description and
implications for the signicance of timing
in social work interventions. Res Soc Work
Pract. 2010;20(5):502---508.

12. Zlotnick C, Zerger S. Survey ndings

on characteristics and health status of

25. Rosenheck R. Cost-effectiveness of

services for mentally ill homeless people:

10. Toro PA. Toward an international

understanding of homelessness. J Soc
Issues. 2007;63(3):461---481.

October 2013, Vol 103, No. 10 | American Journal of Public Health

the application of research to policy and

practice. Am J Psychiatry. 2000;157
(10):1563---1570.
26. Coldwell CM, Bender WS. The
effectiveness of assertive community
treatment for homeless populations with
severe mental illness: a meta-analysis. Am
J Psychiatry. 2007;164(3):393---399.
27. Nelson G, Aubry T, Lafrance A. A
review of the literature on the effectiveness of housing and support, assertive
community treatment, and intensive case
management interventions for persons
with mental illness who have been
homeless. Am J Orthopsychiatry. 2007;
77(3):350---361.
28. The Mckinney---Vento Homeless
Assistance Act as Amended by S. 896
The Homeless Emergency Assistance and
Rapid Transition to Housing (HEARTH)
Act of 2009. US Department of Housing
and Urban Development; 2009. Available
at: http://www.hudhre.info/documents/
HomelessAssistanceActAmendedby
HEARTH.pdf. Accessed May 10, 2013.
29. Harris RP, Helfand M, Woolf SH, et al.
Current methods of the US Preventive
Services Task Force: a review of the process.
Am J Prev Med. 2001;20(3 suppl):21---35.
30. 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---319.
31. Altena AM, Brilleslijper-Kater SN,
Wolf JRLM. Effective interventions for
homeless youth: a systematic review. Am J
Prev Med. 2010;38(6):637---645.
32. Thomson HJ, Thomas S. The effect
direction plot: visual display of nonstandardised effects across multiple outcome domains. Res Synth Methods.
2013;4(1):95---101.
33. Popay J, Roberts HM, Sowden A,
et al. Guidance on the Conduct of Narrative
Synthesis in Systematic Reviews: Final
Report. Swindon, UK: ESRC Methods
Programme; 2006.
34. Conrad KJ, Hultman CI, Pope AR, et al.
Case managed residential care for homeless
addicted veterans. Results of a true experiment. Med Care. 1998;36(1):40---53.
35. Hultman CI, Conrad KJ, Pope AR,
et al. Assessing the implementation of
a case management intervention for the
homeless. In: Albrecht GL, ed. Case and
Care Management. Advances in Medical
Sociology, vol. 6. Greenwich, CT: JAI
Press; 1995:295---323.
36. Marshall M, Lockwood A, Gath D.
Social services case-management for
long-term mental disorders: a randomised
controlled trial. Lancet. 1995;345
(8947):409---412.
37. Orwin RG, Sonnefeld LJ,
Garrisonmogren R, Smith NG. Pitfalls

de Vet et al. | Peer Reviewed | Systematic Review | e25

SYSTEMATIC REVIEW

in evaluating the effectiveness of casemanagement programs for homeless persons: lessons from the NIAAA Community Demonstration Program. Eval Rev.
1994;18(2):153---207.
38. Sosin MR, 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.
39. Braucht GN, Reichardt CS, Geissler
LJ, et al. Effective services for homeless
substance abusers. J Addict Dis. 1995;14
(4):87---109.
40. Cox GB, Walker RD, Freng SA, et al.
Outcome of a controlled trial of the
effectiveness of intensive case management for chronic public inebriates. J Stud
Alcohol. 1998;59(5):523---532.
41. Korr WS, Joseph A. Housing the
homeless mentally ill. J Soc Serv Res.
1996;21(1):53---68.
42. 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---1273.

comparison of the effects of three treatment programs for homeless mentally ill
people. Hosp Community Psychiatry.
1992;43(10):1005---1010.
51. Calsyn RJ, Yonker RD, Lemming
MR, Morse GA, Klinkenberg WD. Impact
of assertive community treatment and
client characteristics on criminal justice
outcomes in dual disorder homeless individuals. Crim Behav Ment Health.
2005;15(4):236---248.
52. 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 Health.
2008;35(4):319---336.
53. Morse GA, Calsyn RJ, Klinkenberg
WD, 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.
54. 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---237.

43. Stahler GJ, Shipley TF Jr, Bartelt D,

Ducette JP, Shandler IW. Evaluating alternative treatments for homeless
substance-abusing men: outcomes and
predictors of success. J Addict Dis.
1995;14(4):151---167.

55. Cheng AL, Lin H, Kasprow W,

Rosenheck RA. Impact of supported
housing on clinical outcomes: analysis of
a randomized trial using multiple imputation technique. J Nerv Ment Dis.
2007;195(1):83---88.

44. Toro PA, Passero Rabideau JM,

Bellavia CW, et al. Evaluating an intervention for homeless persons: results of
a eld experiment. J Consult Clin Psychol.
1997;65(3):476---484.

56. Rosenheck R, Kasprow W, Frisman

L, Liu MW. Cost-effectiveness of supported housing for homeless persons with
mental illness. Arch Gen Psychiatry.
2003;60:940---951.

45. Burger GK, Calsyn RJ, Morse GA,

Klinkenberg WD. Prototypical proles of
the Brief Psychiatric Rating Scale. J Pers
Assess. 2000;75(3):373---386.

57. Essock SM, Mueser KT, Drake RE,

et al. Comparison of ACT and standard
case management for delivering integrated
treatment for co-occurring disorders. Psychiatr Serv. 2006;57(2):185---196.

46. Calsyn RJ, Morse GA, Klinkenberg

WD, Trusty ML, Allen G. The impact
of assertive community treatment on
the social relationships of people who
are homeless and mentally ill. Community Ment Health J. 1998;34(6):
579---593.

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---1043.

47. McBride TD. Duration of homeless

spells among severely mentally ill individuals: a survival analysis. J Community
Psychol. 1998;26(5):473---490.
48. Morse GA, Calsyn RJ, Klinkenberg
WD, et al. An experimental comparison of
three types of case management for
homeless mentally ill persons. Psychiatr
Serv. 1997;48(4):497---503.

59. Lehman AF, Dixon L, Hoch JS, et al.

Cost-effectiveness of assertive community
treatment for homeless persons with severe mental illness. Br J Psychiatry.
1999;174:346---352.

49. Wolff N, Helminiak TW, Morse GA,

et al. Cost-effectiveness evaluation of
three approaches to case management for
homeless mentally ill clients. Am J Psychiatry. 1997;154(3):341---348.

61. Herman D, Opler L, Felix A, et al. A

critical time intervention with mentally ill
homeless men: impact on psychiatric
symptoms. J Nerv Ment Dis. 2000;188(3):
135---140.

50. Morse GA, Calsyn RJ, Allen G,

Tempethoff B, Smith R. Experimental

62. Jones K, Colson P, Valencia E, Susser E.

A preliminary cost effectiveness analysis of

60. Solomon P, Draine J, Meyerson A.

Jail recidivism and receipt of community
mental health services. Hosp Community
Psychiatry. 1994;45(8):793---797.

e26 | Systematic Review | Peer Reviewed | de Vet et al.

an intervention to reduce homelessness

among the mentally ill. Psychiatr Q.
1994;65(4):243---256.
63. Jones K, Colson PW, Holter MC,
et al. Cost-effectiveness of critical time
intervention to reduce homelessness
among persons with mental illness. Psychiatr Serv. 2003;54(6):884---890.
64. 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;95
(10):1760---1766.

76. Oakley D, Dennis DL. Responding

to the needs of homeless people with
alcohol, drug, and/or mental disorders. In:
Baumohl J, ed. Homelessness in America.
Phoenix, AZ: Oryx Press; 1996:179---186.
77. Fitzpatrick S, Christian J. Comparing
homelessness research in the US and
Britain. Int J Housing Policy. 2006;6
(3):313---333.
78. 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.

65. Susser E, Valencia E, Conover S, et al.

Preventing recurrent homelessness among
mentally ill men: a critical time intervention after discharge from a shelter. Am J
Public Health. 1997;87(2):256---262.
66. Kasprow WJ, Rosenheck RA. Outcomes of critical time intervention case
management of homeless veterans after
psychiatric hospitalization. Psychiatr Serv.
2007;58(7):929---935.
67. Rapp CA, Chamberlain R. Case management services for the chronically mentally ill. Soc Work. 1985;30(5):417---422.
68. Brun C, Rapp RC. Strengths-based
case management: individuals perspectives on strengths and the case manager
relationship. Soc Work. 2001;46(3):
278---288.
69. Brown GW, Harris TO, Peto J. Life
events and psychiatric disorders. 2. Nature of causal link. Psychol Med. 1973;3
(2):159---176.
70. Dohrenwend BP, Dohrenwend BS.
Social and cultural inuences on psychopathology. Annu Rev Psychol.
1974;25:417---452.
71. Kessler RC. The effects of stressful
life events on depression. Annu Rev Psychol. 1997;48:191---214.
72. Calsyn RJ, Morse GA, Klinkenberg
WD, Trusty ML. Reliability and validity of
self-report data of homeless mentally ill
individuals. Eval Program Plann. 1997;20
(1):47---54.
73. Goldnger SM, Schutt RK, Seidman
LJ, et al. Self-report and observer measures of substance abuse among homeless
mentally ill persons in the cross-section
and over time. J Nerv Ment Dis. 1996;184
(11):667---672.
74. Appel PW, Hoffman JH, Blane HT,
et al. Comparison of self-report and hair
analysis in detecting cocaine use in
a homeless/transient sample. J Psychoactive Drugs. 2001;33(1):47---55.
75. Perl HI, Jacobs ML. Case management models for homeless persons with
alcohol and other drug problems: an
overview of the NIAAA research demonstration program. NIDA Res Monogr.
1992;127:208---222.

American Journal of Public Health | October 2013, Vol 103, No. 10

Copyright of American Journal of Public Health is the property of American Public Health
Association and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.