Case Management Models in Permanent Supported Housing Programs for People with Complex Behavioral Issues who are Homeless

OBJECTIVE:

The purpose of this article is to examine two evidence-based models of case management for people with co-occurring disorders and histories of chronic homelessness, and to better understand their roles in permanent supported housing. Critical Time Intervention and Assertive Community Treatment are examined in terms of key elements, how they assist in ending homelessness, as well as the role they play in an individual's recovery from co-occurring disorders.

METHODS:

Participants in two supported housing programs were interviewed at baseline and 6 months. One program used Critical Time Intervention (n = 144) and the other used Assertive Community Treatment (n = 90). Staff in both programs were interviewed about their experiences and fidelity assessments were conducted for each program.

RESULTS:

Both programs operated at high levels of fidelity. Despite similar criteria for participation, there were significant differences between groups. Critical Time Intervention participants were older, more likely to be male, more likely to be homeless, and reported greater psychiatric symptoms and higher levels of substance use (all p's < .001). Separate outcome analyses suggested that each program was successful in supporting people to transition from homelessness to stable housing; 88.6% of Assertive Community Treatment participants were homeless at baseline, while at 6 months 30% were homeless (p < .001), and 91.3% of those in the Critical Time Intervention were homeless at baseline, while 44.3% were homeless at 6 months (p < .001). Participants in the Critical Time Intervention program also showed significant decreases in alcohol use, drug use and psychiatric symptoms (all p's < .01). The preliminary results suggest that each case management model is helpful in assisting people with complex behavioral health needs and chronic homelessness to move to stable housing.

CONCLUSIONS:

Permanent supported housing seems to be an effective way to end homelessness among people with co-occurring disorders. Further research is needed to determine which case management models work most effectively with supported housing to help policy makers and program directors make informed decisions in developing these programs.

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By:  Clark C1, Guenther CC1, Mitchell JN1.

• 1 University of South Florida , Department of Mental Health Law and Policy. 
• J Dual Diagn. 2016 Apr 12:0

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The Impact of Comprehensive Case Management on HIV Client Outcomes

In 1990, New York State instituted Comprehensive Medicaid Case Management, also known as Target Case Management (TCM), for people dealing with multiple comorbid conditions, including HIV. 

The goal of TCM is to assist clients in navigating the health care system to increase care engagement and treatment adherence for individuals with complex needs. HIV-positive individuals engaged in care are more likely to be virally suppressed, improving clinical outcomes and decreasing chances of HIV transmission. 

The purpose of this study was to understand the impact of TCM management on outcomes for people with HIV. Data were obtained from Amida Care, which operates not-for-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (i.e., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients. 

Notable findings include increased CD4 counts for TCM clients over the one-year study period, achieving parity with non-TCM clients (i.e., Mean CD4 count > 500). When looking exclusively at TCM clients, there were increases in medication costs over time, which were concomitant with increased care engagement. Current findings demonstrate that TCM is able to achieve its goals of improving care engagement and treatment adherence. 

Subsequent policy changes resulting from the Affordable Care Act and the New York State Medicaid Redesign have made the Health Home the administrator of TCM services. Government entities charged with securing and managing TCM and care coordination for people with HIV should provide thoughtful and reasonable guidance and oversight in order to maintain optimal clinical outcomes for TCM clients and reduce the transmission of HIV.

Full article at:   http://goo.gl/Lz1c6Z

By:  Brennan-Ing M1,2, Seidel L1,3, Rodgers L4, Ernst J1,5, Wirth D5, Tietz D6, Morretti A7, Karpiak SE1,2.

• 1Center on HIV and Aging, ACRIA, New York, New York, United States of America.
• 2College of Nursing, New York University, New York, New York, United States of America.
• 3Graduate School of Social Service, Fordham University, New York, New York, United States of America.
• 4BOOM! Health, Bronx, New York, United States of America.
• 5Amida Care, Inc., New York, New York, United States of America.
• 6Human Resources Administration, City of New York, New York, New York, United States of America.
• 7Columbia University, New York, New York, United States of America. 
• PLoS One. 2016 Feb 5;11(2):e0148865. doi: 10.1371/journal.pone.0148865.

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Low-Intensity Case Management Increases Contact with Primary Care in Recently Released Prisoners

BACKGROUND:

The world prison population is large and growing. Poor health outcomes after release from prison are common, but few programmes to improve health outcomes for ex-prisoners have been rigorously evaluated. The aim of this study was to evaluate the impact of individualised case management on contact with health services during the first 6 months post-release.

METHODS:

Single-blinded, randomised, controlled trial. Baseline assessment with N=1325 adult prisoners in Queensland, Australia, within 6 weeks of expected release; follow-up interviews 1, 3 and 6 months post-release. The intervention consisted of provision of a personalised booklet ('Passport') at the time of release, plus up to four brief telephone contacts in the first 4 weeks post-release.

RESULTS:

Of 1179 eligible participants, 1003 (85%) completed ≥1 follow-up interview. In intention-to-treat analyses, 53% of the intervention group and 41% of the control group reported contacting a general practitioner (GP) at 1 month post-release (difference=12%, 95% CI 5% to 19%). Similar effects were observed for GP contact at 3 months (difference=9%, 95% CI 2% to 16%) and 6 months (difference=8%, 95% CI 1% to 15%), and for mental health (MH) service contact at 6 months post release (difference=8%, 95% CI 3% to 14%).

CONCLUSIONS:

Individualised case management in the month after release from prison increases usage of primary care and MH services in adult ex-prisoners for at least 6 months post-release. Given the poor health profile of ex-prisoners, there remains an urgent need to develop and rigorously evaluate interventions to increase health service contact in this profoundly marginalised population.

Below:  Percentage of intervention group participants contacting a general practitioner (GP) at 1 month post release, according to number of intervention telephone calls completed

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By:  Kinner SA1, Alati R2, Longo M3, Spittal MJ4, Boyle FM2, Williams GM2, Lennox NG5.

• 1Griffith Criminology Institute & Menzies Health Institute Queensland, Griffith University, Brisbane, Australia Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-UQ, The University of Queensland, Brisbane, Australia.
• 2School of Public Health, University of Queensland, Brisbane, Australia.
• 3Drug and Alcohol Services South Australia, Adelaide, Australia.
• 4Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia.
• 5Queensland Centre for Intellectual and Developmental Disability, Mater Research Institute-UQ, The University of Queensland, Brisbane, Australia. 
• J Epidemiol Community Health. 2016 Jan 19. pii: jech-2015-206565. doi: 10.1136/jech-2015-206565. 

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Electronic Case Management with Homeless Youth

Case management, a widely practiced form of service brokerage, is associated with a variety of positive outcomes for homeless youth, but it may be difficult to implement, as youth face logistical barriers to attending in-person meetings. As part of a larger clinical trial, the current study investigates the feasibility of providing electronic case management (ECM) to homeless youth, using cell-phones, texts, email, and Facebook. 

Youth were given prepaid cell-phones and a case manager who provided four ECM sessions every 2-3 weeks over a 3-month period. Contact logs were used to record how many youth engaged in ECM, how many attempts were necessary to elicit engagement, and youths' preferred technology methods for engaging. Although engagement in the number of ECM sessions varied, the majority of youth (87.5%) engaged in at least one ECM session. Youth (41%) most commonly needed one contact before they engaged in an ECM session, and the majority responded by the third attempt. While youth most commonly answered calls directly, their chosen method of returning calls was texting. The majority of youth (80%) described ECM positively, reporting themes of convenience, connection, and accountability. 

The use of ECM, particularly of texting, offers promising implications for providing services to homeless youth.

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By:   Bender K1, Schau N2, Begun S3, Haffejee B4, Barman-Adhikari A5, Hathaway J6.

• 12148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: Kimberly.bender@du.edu.
• 22148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: ndschau@gmail.com.
• 32148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: Stephanie.begun@du.edu.
• 42148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: badiah.haffejee@du.edu.
• 52148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: Anamika.BarmanAdhikari@du.edu.
• 62148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: jessica.kaylyn.hathaway@gmail.com. 

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Script in a Day Intervention for Individuals Who Are Injecting Opioids: A Feasibility Randomized Control Trial

Opioid substitution treatment (OST) reduces the harm of injecting and opioid dependence. The SCID feasibility trial explored the processes of conducting a randomized control trial (RCT) with people who inject drugs (PWID) in a low-threshold agency. Feasibility of the intervention investigated whether offering PWID immediate access to OST via specialist primary care increased numbers in OST at 3 months, compared with offering advice and case management.

Un-blinded RCT was conducted at Bristol Drugs Project needle exchange. A total of 311 individuals were eligible and 100 consented to participate. Trial process outcomes involved exploring OST status at 3 months; secondary outcomes were substance use and health-related quality of life measures.

Follow-up was 86%. At 3 months, 51% intervention and 47% of control participants were in OST (OR of success of intervention 1.17 (0.54-2.57)). Opioid use reduced by 79 and 73%, respectively (OR of intervention success 1.38 (0.5-3.7)). Physical and mental health improved but there was little differences between groups.

The feasibility of conducting the trial was a success, but there was insufficient evidence of an effect compared with intensive case management. Further development and evaluation of case management approaches in low-threshold agencies is warranted.

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By: Beattie A1, Marques EM1, Barber M2, Greenwood R3, Ingram J1, Ayres R4, Neale J4, Rees A4, Coleman B5, Hickman M6.

• 1School of Social and Community Medicine, University of Bristol, Bristol, UK.
• 2Lawrence Hill Health Centre, Bristol, UK.
• 3NIHR Research Design Service-South West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
• 4Bristol Drugs Project, Bristol, UK.
• 5Bristol City Council, Bristol, UK.
• 6School of Social and Community Medicine, University of Bristol, Bristol, UK Bristol City Council, Bristol, UK.  

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Managing High-Risk Patients: The Mass General Care Management Program

The Massachusetts General Care Management Program (Mass General CMP or CMP) was designed as a federally supported demonstration to test the impact of intensive, practice-based care management on high-cost Medicare fee-for-service (FFS) beneficiaries—primarily older persons—with multiple hospitalisations and multiple chronic conditions. The Massachusetts General Care Management Program operated over a 6-year period in two phases (3 years each). 

It started during the first phase at Massachusetts General Hospital, a major academic medical centre in Boston, Massachusetts in collaboration with Massachusetts General Physicians Organisation. During the second phase, the programme expanded to two more affiliated sites in and around the Boston area, including a community hospital, as well as incorporated several modifications primarily focused on the management of transitions to post-acute care in skilled nursing facilities. At the close of the demonstration in July 2012, Mass General Massachusetts General Care Management Program became a component of a new Pioneer accountable care organisation (ACO). The Massachusetts General Care Management Program is focused on individuals meeting defined eligibility criteria who are offered care that is integrated by a case manager embedded in a primary care practice. The demonstration project showed substantial cost savings compared to fee-for-service patients served in the traditional Medicare system but no impact on hospital readmissions. 

The Massachusetts General Care Management Program does not rest upon a “whole systems” approach to integrated care. It is an excellent example of how an innovative care co-ordination programme can be implemented in an existing health-care organisation without making fundamental changes in its underlying structure or the way in which direct patient care services are paid for. The accountable care organisation version of the Massachusetts General Care Management Program includes the staffing structure, standards of practice, collaborative approach to care transitions and information technology tools that were used in the original demonstration project.

Full article at: http://goo.gl/IIgi0w

By: Dennis L. Kodner, PhD, FGSA, Principal, Adjunct Professor

Division of Geriatric Medicine at McGill University, Montreal, Canada

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