Although homelessness is widespread in developing countries, it is also distressingly common in the industrialized world, where it has important implications for public health. A variety of health and mental health conditions place individuals at heightened risk of homelessness while contributing to an elevated risk of morbidity and mortality in affected individuals. Homeless persons also place a large burden on the public health delivery system, attributable to high need combined with lack of access to regular sources of routine medical care. To eradicate widespread homelessness will require a sustained commitment by governments, private organizations, and individuals using a broad variety of approaches. These include explicit recognition of a universal right to decent housing for all citizens coupled with specific targeted approaches, including supported housing and critically timed interventions, aimed toward groups seen as particularly vulnerable to homelessness and social exclusion.

This chapter reviews the current state of evidence on Critical Time Intervention (CTI), methodological strengths and challenges, and recommendations for future research. The authors discuss the effectiveness of CTI and its adaptations by summarizing the evidence derived from experimental and quasi-experimental studies of its impact conducted in the United States, Brazil, Canada, the Netherlands, and the United Kingdom and Europe. The review suggests that CTI has shown a consistent positive impact on reducing homelessness and enhancing service engagement across diverse populations and settings, while impacts in other domains are uneven. The chapter concludes with a discussion of the methodological challenges of the existing evidence and several recommendations for future research. These include factors associated with effective program implementation and the need to understand for whom and under what conditions CTI is most effective.

Abstract Recent US policy shifts strongly promote so-called rapid re-housing strategies. Such strategies aim to minimize the reliance on homeless shelters via helping families and individuals experiencing homelessness quickly obtain and retain housing by providing a short-term rental subsidy combined with targeted, time-limited case management. Critical Time Intervention (CTI) has emerged as a potentially promising approach for delivering this assistance. This chapter describes the experience gained in a pilot study that adapted and implemented CTI to align it with the goals and population needs of persons served by multiple rapid re-housing programs in several regions of a large northeastern state. A process evaluation systematically assessed the successes achieved and challenges faced in successfully implementing the adapted model, leading to recommendations for further refinement of the program.

Permanent supportive housing (PSH) programs are now using Moving On Initiatives (MOIs) to increase homeless service system capacity. These initiatives support tenants with the transition from PSH to mainstream affordable housing by providing them with mainstream housing assistance and various transitional services. Research on this approach has primarily consisted of evaluations of individual programs. Less is known about MOI implementation features across programs. This study utilizes a document review and descriptive survey of 27 MOIs to describe MOI implementation variation and identify common strategies for helping people to move on from PSH. Findings suggest that a wide degree of variation exists in these approaches between and within MOI programs. Two primary types of move-on strategies were identified: moving up and out and transitioning in place. Implications for the homeless service system are discussed.

Abstract This chapter describes the rationale, initial specification, and testing of Critical Time Intervention (CTI) in two randomized trials with unhoused men and women following discharge from institutional settings in New York. Through a decade of work in the nascent homelessness services sector, the authors observed that while considerable attention had so far rightfully focused on designing innovative outreach approaches intended to successfully engage homeless persons on the streets and shelters, few focused systematically on the transition to community care. While engagement and treatment programs must effectively build close, trusting relationships with clients, this often leads to clients depending on program staff to meet a wide range of needs. In contrast, the transition process must help clients move toward greater autonomy and reliance on other sources of support in the community. This underdeveloped stage of service delivery became the focus of the new CTI model.

We explored life in a hotel where unhoused individuals were accommodated during the COVID-19 pandemic. We conducted hour-long semi-structured interviews with twenty residents of a lodging hotel in New York City to: (1) compare their current living situation with prior experiences of homelessness; (2) address how current needs were being met; and (3) assess how hotel living might facilitate residents' transitions to more permanent housing. Although residents were unhappy with some hotel characteristics (e.g. inability to prepare food; sparse furnishings; burdensome security practices), they preferred the hotel to their previous living situations (the streets, in most cases) as hotel rooms offered autonomy, stability, and safety behind locked doors. We utilized the concept of ontological security to guide our analysis of these interview data. Building off this analysis, we argue that homeless services should directly involve people experiencing homelessness to develop residences that are more responsive to their individual needs.

Abstract Residential detoxification programs and other forms of intensive treatment for substance misuse problems are often followed by failure to successfully engage with follow-up services and supports, leading to frequent relapse. These problems are exacerbated among persons with dual diagnoses of substance use and mental health disorders due to the challenges inherent in navigating sequential or parallel mental health and substance abuse services. Although several linkage interventions have been developed specifically for substance abuse residential treatment programs, their efficacy has been limited. This chapter describes a pilot effort that tested Critical Time Intervention (CTI) as a strategy to help enhance continuity of support for persons with substance use problems following residential treatment for substance misuse problems. Preliminary findings indicate that CTI contributed to an improved likelihood of receiving post-discharge treatment, suggesting that it is a potentially useful model to provide re-entry services for persons transitioning from residential substance use treatment.

Abstract Since the original development of Critical Time Intervention (CTI), thinking evolved as further experience and knowledge about the timing of interventions accrued. Together with others, the authors have sought to develop a more general conceptual framework about time-specific interventions. In this chapter, they put forth a tentative schema that represents their current thinking. First, they briefly consider the complexity of seemingly simple concepts of developmental stages and sensitive windows for development and their implications for social interventions. They also differentiate CTIs from time-sensitive interventions. Next, they argue that current trends in human services systems have greatly increased the need for time-sensitive interventions. Finally, they present an organizational context for time-sensitive interventions based upon issues of coordinated care and discuss the use of CTI and other time-sensitive and sequenced interventions in a range of human service contexts.

Abstract This chapter describes several important concerns that either address unanswered questions about the Critical Time Intervention (CTI) model itself or bear on issues related to future adaptation and scale-up. These include the need to validate essential elements of the model via so-called dismantling studies; examination of how to best target the program in order to maximize effectiveness and efficiency; evaluating cost-effectiveness, ideally addressing both individual- and system-level benefits; and specifying ways in which CTI can best complement related intervention models such as permanent supportive housing and Assertive Community Treatment. The chapter also considers workforce issues, including greater use of persons with lived experience as CTI workers and supervisors; strategies for effectively delivering CTI via remote technology; and how CTI can be adapted for use in resource-scarce settings such as the Global South. It then identifies several unanswered research questions and considers important issues related to long-term sustainment of the model. The chapter concludes with a discussion of resources and strategies needed to ensure long-range model sustainment.

Introduction: The COVID-19 Healthcare Personnel Study (CHPS) was designed to assess adverse short-term and long-term physical and mental health impacts of the coronavirus disease-2019 (COVID-19) pandemic on New York's physicians, nurse practitioners, and physician assistants. Methods: Online population-based survey. Survey-weighted descriptive results, frequencies, proportions, and means, with 95% confidence intervals (95% CI). Odds ratios (ORs) for association. Results: Over half (51.5%; 95% CI: 49.1, 54.0) of respondents worked directly with COVID-19 patients; 27.3% (95% CI: 22.5, 32.2) tested positive. The majority (57.6%; 95% CI: 55.2, 60.0) reported a negative impact on their mental health. Negative mental health was associated with COVID-19 symptoms (OR = 1.7, 95% CI: 1.3, 2.1) and redeployment to unfamiliar functions (OR = 1.3, 95% CI: 1.1, 1.6). Conclusions: A majority of New York health care providers treated COVID-19 patients and reported a negative impact on their mental health.

Moving On initiatives present opportunities for stable individuals to move from permanent supportive housing (PSH) into mainstream affordable housing. However, there is a dearth of research on how best to support individuals during this critical transition. This mixed-methods study examines transitional and aftercare services needed and received by individuals moving on through an MOI. Descriptive statistics quantified frequency of services needed and received as reported by movers (n = 43) in a post-move survey. Movers (n = 25) also completed pre- and post-move qualitative interviews regarding the transition and thematic analysis was used to elucidate how and why various supports were helpful to movers. During the pre-move transition, housing navigation and help obtaining financial assistance were the most frequently needed services. Movers relied on informal family and peer support to supplement provider assistance in these areas. Case manager visits were the most frequently needed aftercare service and financial assistance was the greatest unmet post-move need. In both periods, formal peer support was an identified service gap. This MOI generally met the self-identified needs of movers. However, MOIs may benefit from better targeting and more robust services specific to housing discrimination, tenants' rights, formal peer support, and financial assistance.

Critical Time Intervention (CTI) is designed to reduce the risk of homelessness and other adverse outcomes by providing support to individuals during challenging life course transitions. While several narrative reviews suggest the benefit of CTI, the evidence on the model's effectiveness has not been systematically reviewed. This article systematically reviews studies of CTI applied to a variety of populations and transition types. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis for protocols (PRISMA-P) guidelines, we reviewed 13 eligible experimental and quasi-experimental studies. Findings were summarized by individual outcome domains, including housing, service engagement use, hospitalization or emergency services, mental health, substance use, family and social support, and quality of life. CTI had a consistent positive impact on two primary outcomes-reduced homelessness and increased service engagement use-among different populations and contexts. Despite the effectiveness of CTI, the specific mechanisms of the model's positive impacts remain unclear. Implications for practice, policy and research are addressed.

Objective: The aim of this study was to identify factors associated with distress experienced by physicians during their first coronavirus disease 2019 (COVID-19) triage decisions. Methods: An online survey was administered to physicians licensed in New York State. Results: Of the 164 physicians studied, 20.7% experienced severe distress during their first COVID-19 triage decisions. The mean distress score was not significantly different between physicians who received just-in-time training and those who did not (6.0 ± 2.7 vs 6.2 ± 2.8; P = 0.550) and between physicians who received clinical guidelines and those who did not (6.0 ± 2.9 vs 6.2 ± 2.7; P = 0.820). Substantially increased odds of severe distress were found in physicians who reported that their first COVID-19 triage decisions were inconsistent with their core values (adjusted odds ratio, 6.33; 95% confidence interval, 2.03-19.76) and who reported having insufficient skills and expertise (adjusted odds ratio 2.99, 95% confidence interval 0.91-9.87). Conclusion: Approximately 1 in 5 physicians in New York experienced severe distress during their first COVID-19 triage decisions. Physicians with insufficient skills and expertise, and core values misaligned to triage decisions are at heightened risk of experiencing severe distress. Just-in-time training and clinical guidelines do not appear to alleviate distress experienced by physicians during their first COVID-19 triage decisions.

Back to table of contents Previous article Next article ViewpointFull AccessFrom Shelters to Hotels: An Enduring Solution to Ending Homelessness for Thousands of AmericansDeborah K. Padgett, Ph.D., M.P.H., and Daniel Herman, M.S.W., Ph.D.Deborah K. PadgettSearch for more papers by this author, Ph.D., M.P.H., and Daniel HermanSearch for more papers by this author, M.S.W., Ph.D.Published Online:13 Jul 2021https://doi.org/10.1176/appi.ps.202100170AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail As the COVID-19 pandemic raged in April 2020, public health authorities recognized that “dedensifying” homeless shelters was a major public health priority. In a move that was both financially possible (utilizing Federal Emergency Management Agency [FEMA] funding under the Coronavirus Aid, Relief, and Economic Security Act) and guaranteed to save lives, many local governments authorized shelter providers to move residents into hotels left empty by a dramatic drop in tourism and business travel. The total number of homeless persons moved nationally because of COVID-19 is unknown, but it was substantial—approximately 9,500 in New York City and 4,300 in Los Angeles County alone.A Bold Approach Is PossibleFrom the outset, anecdotal reports underscored the positive impacts on shelter residents who suddenly found themselves living in the relative comfort of a climate-controlled room with clean linens, private bathroom, and—last but not least—an address and stable living situation. Although presumed temporary because of an expected end of FEMA funding, this housing solution offered much-needed relief for residents from the dangers of crowded shelters or life on the streets.Most shelters—especially those housing persons with serious mental illness awaiting supportive housing placements—relocated their support staff to the hotels where they maintained onsite services. Perhaps not surprisingly, a few hotels faced local opposition as these relocated hotel residents were considered unwelcome in some neighborhoods. At this juncture, the aphorism “never let a serious crisis go to waste” seems fitting. Ending homelessness for thousands of individuals and families can be achieved by taking advantage of this once-in-a-lifetime opportunity to convert empty hotels and unused business properties into affordable housing. If the necessary political will and organizational innovation can be summoned and sustained to support this strategy, the expensive—and dehumanizing—circuit that homeless persons often traverse between streets, shelters, jails, and hospitals (1) can be broken.This bold approach is already under way in California, where the state’s Project RoomKey was expanded to Project HomeKey in June 2020 with the intention of combining federal and state funds to purchase and convert hotels into more permanent housing. However, the scope of this initiative is designed to house <30% of the homeless population (https://thehill.com/opinion/finance/509666-what-the-pandemic-taught-us-about-the-homeless-and-what-we-shouldnt-forget). Other states, including Oregon, Vermont, New Mexico, and Minnesota, are considering similar initiatives (2). With the numbers of homeless persons almost certain to rise in 2021 and beyond, we have reached an historic inflection point. Hotels should be used as long as necessary to replace congregate shelters, and those that can be converted to permanent apartment units should undergo needed alterations as soon as possible.Life in Hotels: Some Promising OutcomesThe virtual absence of empirical research—impeded in part by COVID-19 restrictions—has left us with limited evidence describing the impact of moving homeless people from streets and shelters into hotels. However, the evidence so far is encouraging. A longitudinal study currently under way in Seattle used interviews and administrative data to track individual outcomes after transitions from homelessness to hotel living. Preliminary findings are uniformly positive: reduced rates of COVID-19 infection, improved mental and physical well-being, reduced interpersonal conflicts (and 911 calls), and more transitions to permanent housing, as well as increased engagement with service providers (3).One agency in New York City reported a two-thirds decrease in substance use–related incidents (including 911 calls) after shelter residents relocated to hotel rooms (https://www.projectrenewal.org/lucerne). A qualitative interview study of hotel residents in New York revealed the benefits extended to multiple domains, including general medical and mental health, personal hygiene, feelings of safety (from COVID-19 as well as violence), improved sleep, diet and nutrition, easier access to public assistance such as food stamps, and other advantages of having a stable address for applying for jobs or permanent housing and making and keeping appointments with providers. Relationships with hotel staff were positive, and problematic incidents were infrequent and typically handled by support staff from the sponsoring agency (Padgett, Bond, and Wusinich, 2021, submitted manuscript).Best Practices Are Available to HelpTwo evidence-based practices—Housing First (HF) and Critical Time Intervention (CTI)—present opportunities for ensuring successful moves from shelters to hotels and homes. HF is an approach that prioritizes housing without behavioral contingencies, has been adopted widely, and provides guidance on accelerating the path to independent living for persons experiencing homelessness, particularly those with serious mental illness and co-occurring substance disorders (4). CTI is an empirically supported, time-limited care coordination model that could assist hotel residents in connecting with community resources, including formal services, informal supports, and permanent housing (5). Both HF and CTI could also include efforts to help build mutual support among hotel residents, consumer-led advocacy efforts, and other forms of collective action.Few would argue, especially not the individuals who are experiencing homelessness (https://www.streetroots.org/news/2020/05/22/survey-moving-motels-hotels-top-choice-unhoused-people), that shelters are preferable to hotels. Yet some shelter staff may experience new challenges resulting from this transition. For example, staff have to adjust to providing services to clients who are not under the level of scrutiny typical of congregate settings. The fact that clients “can just close the door on us” may run up against a clinical mandate to detect substance use or other infractions. Thus, key tenets of HF, including consumer choice and harm reduction, may be difficult for some providers to accept. From the client’s perspective, this viewpoint is problematic. One interviewee in Padgett et al.’s study (Padgett, Bond, and Wusinich, 2021, submitted manuscript) reported that during her stay in a city-run hotel, multiple “bed checks” were conducted throughout the night that interrupted her sleep and invaded her sense of privacy. Despite the existence of these sometimes opposing interests of residents and providers, we note that the consumer preference for hotel living, combined with greater protection from COVID-19 and the stresses of crowded shelters, clearly renders the transition to hotels a win on multiple fronts for persons experiencing homelessness.There is immense diversity among single adults experiencing homelessness—a minority diagnosed as having a serious mental illness, those in the throes of addiction, and the “silent majority” who live with trauma from life on the streets and extreme poverty but do not have serious mental illness or addictions. Many members of all of these groups are able and willing to work if given adequate supports such as job training, additional schooling, and similar opportunities. A stable home makes this far more likely.ConclusionsWe fear that hotels might end up being just temporary waystations to mitigate the immediate impact of COVID-19 on the homeless population if the opportunity to convert them to more stable housing is lost or, in the places where this housing approach is being trialed, becomes derailed by feasibility challenges. There are certainly obstacles to overcome. Changes will be needed in zoning requirements, in shortening wait times for building permits, and in raising capital to pay for support services and other costs not covered by federal or state funds. It is also possible that some hotel conversions will devolve into troubled institutional settings because of programmatic neglect. Ultimately, of course, hotel conversions must be considered within the larger context of increasing multiple forms of affordable housing, hopefully made possible by an anticipated new infusion of federal funds via the American Rescue Plan Act.There is a growing realization that the status quo is not only expensive but also not working. It took a calamitous pandemic to open the door to potentially real and lasting transformations in homeless policies and practices. Failure to act on this immense opportunity will continue to deny our most vulnerable fellow citizens the fundamental right to safe and secure accommodation.Silver School of Social Work, New York University (Padgett), and Silberman School of Social Work, Hunter College (Herman), New York CitySend correspondence to Dr. Padgett ([email protected]).This Viewpoint was written on behalf of HOmeless Transitions from Emergency Living Situations-NYC (HOTELS-NYC), a research collaborative consisting of (besides the two authors) Ezra Susser, M.D., Dr.PH., Mailman School of Public Health, Columbia University, and New York State Psychiatric Institute; Kim M. Fader, M.A., Mailman School of Public Health, Columbia University; and Sarah Conover, M.P.H., Jonathan Prince, M.S.W., Ph.D., James M. Mandiberg, M.S.W., Ph.D., and Ryan F. Savino, M.B.A., L.M.S.W., Silberman School of Social Work, Hunter College, New York City.The authors report no financial relationships with commercial interests.References1. Hopper K, Jost J, Hay T, et al.: Homelessness, severe mental illness, and the institutional circuit. Psychiatr Serv 1997; 48:659–665Link, Google Scholar2. Ellis EG: The lasting impact of COVID 19 on homelessness in the US. Wired. Jan 28, 2021. https://www.wired.com/story/covid-19-homelessness-futureGoogle Scholar3. Colburn G, Fyall R, Thompson S, et al.: Impact of Hotels as Non-Congregate Emergency Shelters: An Analysis of Investments in Hotels as Emergency Shelter in King County, WA During the COVID-19 Pandemic. Seattle, University of Washington, 2020.https://regionalhomelesssystem.org/wp-content/uploads/2020/11/Impact-of-Hotels-as-ES-Study_Full-Report_Final-11302020.pdfGoogle Scholar4. Padgett DK, Henwood BF, Tsemberis S: Housing First: Ending Homelessness, Transforming Systems and Changing Lives. New York, Oxford Press, 2015Crossref, Google Scholar5. Herman DB, Conover S, Gorroochurn P, et al.: Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatr Serv 2011; 62:713–719Link, Google Scholar FiguresReferencesCited byDetailsCited byFrom the streets to a hotel: a qualitative study of the experiences of homeless persons in the pandemic era9 January 2022 | Journal of Social Distress and Homelessness, Vol. 29 Volume 72Issue 9 September 01, 2021Pages 986-987 Metrics Featured in Psychiatric Services From Pages to Practice. KeywordsHomelessnessHousing needsCOVID-19Homeless shelterMental healthPDF download History Received 25 March 2021 Revised 22 April 2021 Accepted 7 May 2021 Published online 13 July 2021 Published in print 1 September 2021

Hoarding disorder has significant health consequences, including the devastating threat of eviction. In this pilot study, critical time intervention (CTI), an evidence-based model of case management shown to be effective for vulnerable populations, was adapted for individuals with severe symptoms of hoarding disorder at risk for eviction (CTI-HD). Of the 14 adults who enrolled, 11 participants completed the 9-month intervention. Completers reported a modest decrease in hoarding severity, suggesting that, while helpful, CTI-HD alone is unlikely to eliminate the risk of eviction for individuals with severe symptoms of hoarding disorder.

Purpose: To support future development and refinement of social work–led intervention programs among patients with firearm injuries and to demonstrate how a fidelity assessment can be used to adjust and refine intervention delivery in an ongoing trial. Method: We conducted a fidelity assessment of a randomized controlled trial of a social work–led intervention among patients with a firearm injury. Results: We found that our study intervention was well implemented, meeting 70% of the fidelity assessment score items, however, noted lower fidelity with client-based items. Discussion: As a result of fidelity assessment findings, we refined intervention delivery to improve implementation fidelity including beginning to review cases of all patients each month rather than focusing on patients in crisis. Our fidelity assessment process and findings offer insight into the challenges of implementing an intervention among patients with firearm injuries and highlight the value of monitoring intervention fidelity during an ongoing trial.

Social quality is the extent to which people are able to participate in social relationships under conditions which enhance their well-being, capacities and potential and enables them to shape their own circumstances and contribute to societal development. We assessed whether women in homeless shelters differed from men on social quality factors that constitute the quality of their daily life and whether factor scores changed at a different rate for women and men after shelter exit. Data were collected as part of a randomised controlled trial. In 18 shelters across the Netherlands, 183 participants were recruited between December 2010 and December 2012 and followed for 9 months. Adults were eligible if they were about to move from shelter to (supported) independent housing and their shelter stay had been shorter than 14 months. At baseline, women were significantly younger than men. They were more likely to have children, to have minor children staying with them, to be lower educated, to be unemployed and to have been victimised than men. Women had used more services and reported lower self-esteem, less satisfaction with health and empowerment and higher psychological distress. They were less likely than men to have used alcohol excessively or cannabis. We found no significant differences between women and men in changes over time on the social quality factors. As women were disadvantaged at baseline compared to men regarding many factors, we concluded that women in homeless shelters are a particularly vulnerable group. Moreover, an opportunity remains for shelter services to improve women's social quality during and after their shelter stay.

Release from prison is a vulnerable period, especially for people with severe mental illness. Critical Time Intervention (CTI) can be effective in improving service access and reducing negative outcomes. Nested within a randomised controlled trial of CTI, qualitative interviews were conducted with trial participants in both intervention (CTI) and treatment as usual (TAU) arms, CTI managers delivering the intervention and associated professionals. Data were analysed using a framework approach. Four themes were identified: uncertainty about post-release plans; inadequate housing provision; support during transition; and continuity of care. Interviewees shared common concerns about transition into the community but CTI participants felt less anxious about release and reported receiving more support with housing, access to services and community reintegration than during previous periods of incarceration. Professionals raised concerns about the time-limited nature of CTI and the impact of austerity measures on the availability of support following CTI. Implications for service delivery will be discussed.